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Scaling Note Quality Assessment Across an Academic Medical Center with AI and GPT-4

Feldman, Jonah; Hochman, Katherine A.; Guzman, Benedict Vincent; Goodman, Adam; Weisstuch, Joseph; Testa, Paul
Electronic health records have become an integral part of modern health care, but their implementation has led to unintended consequences, such as poor note quality. This case study explores how NYU Langone Health leveraged artificial intelligence (AI) to address the challenge to improve the content and quality of medical documentation. By quickly and accurately analyzing large volumes of clinical documentation and providing feedback to organizational leadership and individually to providers, AI can help support a culture of continuous note quality improvement, allowing organizations to enhance a critical component of patient care.
ISSN: 2642-0007
CID: 5659992

Novel Note Templates to Enhance Signal and Reduce Noise in Medical Documentation: Prospective Improvement Study

Feldman, Jonah; Goodman, Adam; Hochman, Katherine; Chakravartty, Eesha; Austrian, Jonathan; Iturrate, Eduardo; Bosworth, Brian; Saxena, Archana; Moussa, Marwa; Chenouda, Dina; Volpicelli, Frank; Adler, Nicole; Weisstuch, Joseph; Testa, Paul
Background: The introduction of electronic workflows has allowed for the flow of raw uncontextualized clinical data into medical documentation. As a result, many electronic notes have become replete of "noise" and deplete clinically significant "signals." There is an urgent need to develop and implement innovative approaches in electronic clinical documentation that improve note quality and reduce unnecessary bloating. Objective: This study aims to describe the development and impact of a novel set of templates designed to change the flow of information in medical documentation. Methods: This is a multihospital nonrandomized prospective improvement study conducted on the inpatient general internal medicine service across 3 hospital campuses at the New York University Langone Health System. A group of physician leaders representing each campus met biweekly for 6 months. The output of these meetings included (1) a conceptualization of the note bloat problem as a dysfunction in information flow, (2) a set of guiding principles for organizational documentation improvement, (3) the design and build of novel electronic templates that reduced the flow of extraneous information into provider notes by providing link outs to best practice data visualizations, and (4) a documentation improvement curriculum for inpatient medicine providers. Prior to go-live, pragmatic usability testing was performed with the new progress note template, and the overall user experience was measured using the System Usability Scale (SUS). Primary outcome measures after go-live include template utilization rate and note length in characters. Results: In usability testing among 22 medicine providers, the new progress note template averaged a usability score of 90.6 out of 100 on the SUS. A total of 77% (17/22) of providers strongly agreed that the new template was easy to use, and 64% (14/22) strongly agreed that they would like to use the template frequently. In the 3 months after template implementation, general internal medicine providers wrote 67% (51,431/76,647) of all inpatient notes with the new templates. During this period, the organization saw a 46% (2768/6191), 47% (3505/7819), and 32% (3427/11,226) reduction in note length for general medicine progress notes, consults, and history and physical notes, respectively, when compared to a baseline measurement period prior to interventions. Conclusions: A bundled intervention that included the deployment of novel templates for inpatient general medicine providers significantly reduced average note length on the clinical service. Templates designed to reduce the flow of extraneous information into provider notes performed well during usability testing, and these templates were rapidly adopted across all hospital campuses. Further research is needed to assess the impact of novel templates on note quality, provider efficiency, and patient outcomes.
ISSN: 2561-326x
CID: 5499932

Quality and Safety Outcomes of a Hospital Merger Following a Full Integration at a Safety Net Hospital

Wang, Erwin; Arnold, Sonia; Jones, Simon; Zhang, Yan; Volpicelli, Frank; Weisstuch, Joseph; Horwitz, Leora; Rudy, Bret
Importance/UNASSIGNED:Hospital consolidations have been shown not to improve quality on average. Objective/UNASSIGNED:To assess a full-integration approach to hospital mergers based on quality metrics in a safety net hospital acquired by an urban academic health system. Design, Setting, and Participants/UNASSIGNED:This quality improvement study analyzed outcomes for all nonpsychiatric, nonrehabilitation, non-newborn patients discharged between September 1, 2010, and August 31, 2019, at a US safety net hospital that was acquired by an urban academic health system in January 2016. Interrupted time series and statistical process control analyses were used to assess the main outcomes and measures. Data sources included the hospital's electronic health record, Centers for Medicare & Medicaid Services Hospital Compare, and nursing quality reports. Exposures/UNASSIGNED:A full-integration approach to the merger that included: (1) early administrative and clinical leadership integration with the academic health system; (2) rapid transition to the academic health system electronic health record; (3) local ownership of quality metrics; (4) system-level goals with real-time actionable analytics through combined dashboards; and (5) implementation of value-based and other analytic-driven interventions. Main Outcomes and Measures/UNASSIGNED:The primary outcome was in-hospital mortality. Secondary outcomes included 30-day readmission, patient experience, and hospital-acquired conditions. Results/UNASSIGNED:The 122 348 patients in the premerger (September 2010 through August 2016) and the 58 904 patients in the postmerger (September 2016 through August 2019) periods had a mean (SD) age of 55.5 (22.0) years; the total sample of 181 252 patients included 112 191 women (61.9%), the payor mix was majority governmental (144 375 patients [79.7%]), and most admissions were emergent (121 469 patients [67.0%]). There was a 0.71% (95% CI, 0.57%-0.86%) absolute (27% relative) reduction in the crude mortality rate and 0.95% (95% CI, 0.83%-1.12%) absolute (33% relative) in the adjusted rate by the end of the 3-year intervention period. There was no significant improvement in readmission rates after accounting for baseline trends. There were fewer central line infections per 1000 catheter days, fewer catheter-associated urinary tract infections per 1000 discharges, and a higher likelihood of patients recommending the hospital or ranking it 9 or 10. Conclusions and Relevance/UNASSIGNED:In this quality improvement study, a hospital merger with a full-integration approach to consolidation was found to be associated with improvement in quality outcomes.
PMID: 34989794
ISSN: 2574-3805
CID: 5107272

Protocolized Urine Sampling is Associated with Reduced Catheter-Associated Urinary Tract Infections: A Pre- and Post-intervention Study

Frontera, Jennifer A; Wang, Erwin; Phillips, Michael; Radford, Martha; Sterling, Stephanie; Delorenzo, Karen; Saxena, Archana; Yaghi, Shadi; Zhou, Ting; Kahn, D Ethan; Lord, Aaron S; Weisstuch, Joseph
BACKGROUND:Standard urine sampling and testing techniques do not mitigate against detection of colonization, resulting in false positive catheter-associated urinary tract infections (CAUTI). We aim to evaluate if a novel protocol for urine sampling and testing reduces rates of CAUTI. METHODS:A pre-intervention and post-intervention study with a contemporaneous control group was conducted at two campuses (test and control) of the same academic medical center. The test campus implemented a protocol requiring urinary catheter removal prior to urine sampling from a new catheter or sterile straight catheterization, along with urine bacteria and pyuria screening prior to culture. Primary outcomes were test campus CAUTI rates compared between each 9-month pre- and post-intervention epoch. Secondary outcomes included the percent reductions in CAUTI rates compared between the test campus and a propensity-score matched cohort at the control campus. RESULTS:  A total of 7,991 patients from the test campus were included in the primary analysis, and 4,264 were included in the propensity-score matched secondary analysis. In primary analysis, CAUTI/1000-patients was reduced by 77% (6.6 to 1.5), CAUTI/1000-catheter days by 63% (5.9 to 2.2) and urinary catheter days/patient by 37% (1.1 to 0.69, all P≤0.001). In propensity score-matched analysis, CAUTI/1000-patients was reduced by 82% at the test campus versus 57% at the control campus, CAUTI/1000 catheter-days declined by 68% versus 57% and catheter-days/patient decreased by 44% versus 1% (all P<0.001). CONCLUSIONS: Protocolized urine sampling and testing aimed at minimizing contamination by colonization was associated with significantly reduced CAUTI infection rates and urinary catheter days.
PMID: 32776142
ISSN: 1537-6591
CID: 4556052


Frontera, Jennier; Weisstuch, Joseph; Phillips, Michael; Radford, Martha; Sterling, Stephanie; Delorenzo, Karen; Saxena, Archana; Wang, Erwin
ISSN: 0090-3493
CID: 4227692

Predictors of contrast-induced nephropathy in patients undergoing conventional angiography for acute hemorrhage [Meeting Abstract]

Haber, Z; Charles, H; Weisstuch, J; Deipolyi, A
Purpose: To evaluate factors predicting contrast-induced nephropathy (CIN) after conventional angiography for symptomatic bleeding. Materials: All angiograms for intra-abdominal bleeding at one academic center (1/2013-6/2015) were reviewed retrospectively. Studies included 66 angiograms in 60 patients (20 women; 40 men) with a mean age of 63 yr (range 21-92). Indications included gastrointestinal (38), urinary tract (7), uterine (5), hepatic (3), splenic (2), extremity (1), or other abdominal (6) bleeding, and hemoptysis (4). Variables assessed included age, sex, history of congestive heart failure (CHF) or diabetes (DM), injected contrast volume or type, and the presence of active extravasation on angiography. Pulse, mean arterial pressure (MAP), and last glomerular filtration rate (GFR) were recorded immediately preceding the examination. The percent change in hematocrit (DELTAHct) and units of packed red blood cells (pRBC) were measured over the 24 hr prior to each angiogram. Studies resulting in CIN (25% increase in creatinine from baseline or 0.5 mg/dL increase in absolute value 48-72 hr from contrast administration) were compared to those not resulting in CIN with parametric and nonparametric tests, and logistic regression. Results: Of 66 angiograms, 10 (15%) resulted in CIN; 56 (85%) did not. Age, sex, CHF, DM, contrast volume/type, pulse, MAP, presence of active extravasation, and the pRBCs or DELTAHct over the 24 hours prior to angiogram did not significantly differ between groups. GFR was significantly lower in patients who experienced CIN (57 vs. >60; p=0.02). On logistic regression, GFR was the only independent predictor for CIN (p=0.03): 67% of patients with severe renal impairment (GFR < 30), 29% of patients with mild-moderate impairment (GFR 30-60), and 8% of patients with normal renal function (GFR > 60) developed CIN. Conclusions: CIN is relatively common following conventional angiography for symptomatic hemorrhage, in light of low rates reported for patients without hemorrhage after contrast-enhanced CT. Pre-existing renal impairment, the only independent predictor of CIN, can help triage candidates for angiographic investigation and therapy and identify patients in need of renal protection
ISSN: 1051-0443
CID: 2094892

Variables predicting active extravasation and contrast-induced nephropathy in conventional angiography for acute intraabdominal bleeding [Meeting Abstract]

Haber, Z; Charles, H W; Weisstuch, J; Kovacs, S; Deipolyi, A R
Purpose: To identify variables predicting active extravasation and contrast-induced nephropathy (CIN) in angiography performed for acute bleeding. Material and methods: We retrospectively reviewed all conventional angiograms performed for acute bleeding (1/2013 to 6/2015), including 75 angiograms (46 gastrointestinal; 29 other sources of intra-abdominal bleeding cases) in 70 patients (26 women; 44 men) with a mean age of 59 (range 21-92) years. We recorded demographic information, comorbidities, vital signs immediately preceding angiography, post-procedure complications, and change in hematocrit (DELTAHct) and fluids and blood products administered over the 24 hours prior to angiography. Results: Of 75 exams, 20 (27%) showed contrast extravasation. DELTAHct was the only independent predictor of contrast extravasation (p=0.017). Patients with active extravasation had larger DELTAHct than those without extravasation (-17% vs. -1%; p=0.01). CIN occurred after 10 of 66 angiograms (15%), with GFR being the only independent predictor (p=0.03); 8% of patients with normal renal function (GFR>60) developed CIN; 29% of patients with mild-moderate impairment (GFR 30-60) developed CIN; and 67% of patients with severe renal impairment (GFR<30) developed CIN after angiography. Conclusion: Greater decrease in hematocrit over the 24 hours prior to angiography for intra-abdominal bleeding is an independent predictor of active extravasation, whereas pre-existing renal impairment is the independent predictor of CIN. The potential benefit of diagnosing active extravasation in patients with large hematocrit declines can be weighed against the risk of renal impairment
ISSN: 1432-086x
CID: 2395452

Iatrogenic Manganism: Acute Manganese Toxicity With Involvement Of The Globus Pallidus [Meeting Abstract]

Murthy, V; Mahmoudi, M; Basavaraj, A; Mendelson, J; Weisstuch, J; Schwartz, DR
ISSN: 1535-4970
CID: 2161902

Expression of endothelial protein C receptor in cortical peritubular capillaries associates with a poor clinical response in lupus nephritis

Izmirly, Peter M; Barisoni, Laura; Buyon, Jill P; Kim, Mimi Y; Rivera, Tania L; Schwartzman, Julie S; Weisstuch, Joseph M; Liu, David T; Bernstein, Stephen; Tseng, Chung-E; Belmont, Howard M; Esmon, Charles T; Merrill, Joan T; Askanase, Anca D; Thomas, David B; Clancy, Robert M
OBJECTIVE: To study the membrane expression of endothelial protein C receptor (mEPCR) in the renal microvasculature in lupus nephritis (LN) as a potential marker of injury and/or prognostic indicator for response to therapy. METHODS: mEPCR expression was analysed by immunohistochemistry in normal kidney and in 59 biopsies from 49 patients with LN. Clinical parameters were assessed at baseline, 6 months and 1 year. RESULTS: mEPCR was expressed in the medulla, arterial endothelium and cortical peritubular capillaries (PTCs) in all biopsies with LN but not in the cortical PTCs of normal kidney. Positive mEPCR staining in >25% of the PTCs was observed in 16/59 biopsies and associated with poor response to therapy. Eleven (84.6%) of 13 patients with positive staining for mEPCR in >25% of the PTCs and follow-up at 6 months did not respond to therapy, compared with 8/28 (28.6%) with mEPCR staining in < or =25% PTCs, P = 0.0018. At 1 year, 10 (83.3%) of 12 patients with positive mEPCR staining in >25% of the PTCs did not respond to therapy (with two progressing to end-stage renal disease) compared with 8/24 (33.3%) with positive staining in < or =25% of the PTCs, P = 0.0116. Although tubulo-interstitial damage (TID) was always accompanied by mEPCR, this endothelial marker was extensively expressed in the absence of TID suggesting that poor response could not be attributed solely to increased TID. mEPCR expression was independent of International Society of Nephrology/Renal Pathology Society class, activity and chronicity indices. CONCLUSION: Increased mEPCR expression in PTCs may represent a novel marker of poor response to therapy for LN
PMID: 19286697
ISSN: 1462-0324
CID: 100419

Current therapies for lupus nephritis in an ethnically heterogeneous cohort

Rivera, Tania L; Belmont, H Michael; Malani, Seema; Latorre, Melissa; Benton, Lauri; Weisstuch, Joseph; Barisoni, Laura; Tseng, Chung-E; Izmirly, Peter M; Buyon, Jill P; Askanase, Anca D
OBJECTIVE: To evaluate responses to mycophenolate mofetil (MMF) and intravenous cyclophosphamide (CYC) in lupus nephritis in a multiethnic population. METHODS: This was a retrospective study of all patients with systemic lupus erythematosus (SLE) that underwent kidney biopsy at New York University Medical Center. Patients with followup of at least 6 months were included. Clinical response was defined as complete (return to +/- 10% of normal) or partial (improvement of 50% in abnormal renal measurements). RESULTS: Ninty-nine patients were included in the study: 86% females, 86% non-Caucasian, age 34.2 +/- 1.1 years, 62% with proliferative nephritis (PN; ISN/RPS-III and IV), and 32% with membranous nephritis (MN; ISN/RPS-V). Of the 70 patients with PN, 37 were treated with CYC and 33 with MMF. The baseline characteristics of the 2 treatment groups were different in the incidence of ISN/RPS-IV, values of serum creatinine and serum albumin, and type of insurance (p < 0.05). The response rate was greater in the MMF than in the CYC group (70% vs 41%). Responses to MMF were different in Asians (11/11), Caucasians (4/5), African Americans (3/5), and Hispanics (5/11). Responses to CYC had a similar distribution (Asians 6/10, Caucasians 4/5, African Americans 4/9, Hispanics 1/11). In the MN group (N = 23) responses were similar to the PN group (73% MMF and 38% CYC). After adjusting for race, serum creatinine, serum albumin, type of insurance, and class of nephritis, in a logistic regression model, response to MMF was superior to CYC: OR 6.2 (95% CI 1.9-20.2). Hispanics had worse outcome than Caucasians (OR 0.17). Longterm followup suggested no difference in maintenance with MMF or CYC. CONCLUSION: After controlling for the fact that less severe nephritis is preferentially treated with MMF, we found overall that response to MMF was superior to CYC. In this US population, ethnicity was observed to have an influence on response
PMID: 19040310
ISSN: 0315-162x
CID: 93732