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BACKGROUND: Previous studies found that documentation of comorbidities differed when Veterans received care within versus outside Veterans Health Administration (VHA). Changes to medical center funding, increased attention to performance reporting, and expansion of Clinical Documentation Improvement programs, however, may have caused coding in VHA to change. METHODS: Using repeated cross-sectional data, we compared Elixhauser-van Walraven scores and Medicare Severity Diagnosis Related Group (DRG) severity levels for Veterans admissions across settings and payers over time, utilizing a linkage of VHA and all-payer discharge data for 2012-2017 in seven US states. To minimize selection bias, we analyzed records for Veterans admitted to both VHA and non-VHA hospitals in the same year. Using generalized linear models, we adjusted for patient and hospital characteristics. RESULTS: Following adjustment, VHA admissions consistently had the lowest predicted mean comorbidity scores (4.44 (95% CI 4.34-4.55)) and lowest probability of using the most severe DRG (22.1% (95% CI 21.4%-22.8%)). In contrast, Medicare-covered admissions had the highest predicted mean comorbidity score (5.71 (95% CI 5.56-5.85)) and highest probability of using the top DRG (35.3% (95% CI 34.2%-36.4%)). CONCLUSIONS: More effective strategies may be needed to improve VHA documentation, and current risk-adjusted comparisons should account for differences in coding intensity.

Advance care planning (ACP) has been recognized as crucial by patients, families, and clinicians; however, different definitions and measurements have led to inconsistencies in practice and mixed evidence in the literature. This narrative review explores ACPs evolution, innovations, and outcomes using thematic analysis to synthesize data from randomized controlled trials, reviews, and editorials. Key findings include (1) ACP has evolved over the past several decades from a sole focus on code status and advance directive (AD) forms to a continuum of care planning over the life course focused on tailored preparation for patients and surrogate decision-makers and (2) ACP measurement has evolved from traditional outcome metrics, such as AD completion, to a comprehensive outcomes framework that includes behavior change theory, systems, implementation science, and a focus on surrogate outcomes. Since the recent development of an ACP consensus definition and outcomes framework, high-quality trials have reported mainly positive outcomes for interventions, especially for surrogates, which aligns with the patient desire to relieve decision-making burden for loved ones. Additionally, measurement of clinically meaningful ACP information, including documented goals of care discussions, is increasingly being integrated into electronic health records (EHR), and emerging, real-time assessments and natural language processing are enhancing ACP evaluation. To make things easier for patients, families, and care teams, clinicians and researchers can use and disseminate these evolved definitions; provide patients validated, easy-to-use tools that prime patients for conversations and decrease health disparities; use easy-to-access clinician training and simple scripts for interdisciplinary team members; and document patients values and preferences in the medical record to capture clinically meaningful ACP so this information is available at the point of care. Future efforts should focus on efficient implementation, expanded reimbursement options, and seamless integration of EHR documentation to ensure ACPs continued evolution to better serve patients and their care partners.

ObjectivesThe number of surgeries performed in the United States has increased over the past two decades, with a shift to the ambulatory setting. Perioperative complications and mortality pose significant health care burdens. Inadequate preoperative assessment and documentation contribute to communication failure and poor patient outcomes. The aim of this quality improvement project was to design and implement a preoperative evaluation documentation template that not only improved communication during the perioperative pathway but also enhanced the overall user experience.MethodsWe implemented a revamped evidence-based documentation template in the electronic medical records of a health care organization across three internal medicine clinics on the downtown campus and seven satellite family medicine clinics. A pre- and postintervention design was used to assess the template utilization rate and clinician satisfaction.ResultsThe preoperative template utilization rate increased from 51.2% at baseline to 66.5% after the revamped template "went live" (p

BACKGROUND/PROBLEM: Advance care planning (ACP) pragmatic trials are needed. PROPOSED SOLUTION: We determined key system-level activities to implement ACP interventions for a cluster-randomized pragmatic trial. We identified patients with serious illness from 50 primary care clinics across three University of California health systems using a validated algorithm. If patients lacked documented ACP within the last 3 years, they were eligible for an intervention: (Arm 1) an advance directive (AD); (Arm 2) AD + PREPAREforYourCare.org; (Arm 3) AD + PREPARE + lay health navigator outreach. Triggered by an appointment, we mailed and sent interventions through automated electronic health record (EHR) messaging. We collaborated with patients/caregivers, clinicians, payors, and national/health system leader advisors. We are currently finalizing 24 months follow-up data. OUTCOMES/METHODS: We used the Consolidated Framework for Implementation Research (CFIR) and Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) frameworks to track secular trends and implementation efforts. KEY MESSAGE/RESULTS: Required multisite, system-level activities: 1) obtaining leadership, legal/privacy, and EHR approvals; 2) standardizing ACP documentation; 3) providing clinician education; 3) validating an automated serious illness identification algorithm; 4) standardizing ACP messaging with input from over 100 key advisors; 5) monitoring secular trends (e.g., COVID); and 6) standardizing ACP workflows (e.g., scanned ADs). Of 8707 patients with serious illness, 6883 were eligible for an intervention. Across all arms, 99% received the mailed intervention, 78.3% had an active patient portal (64.2% opened intervention), and 90.5% of arm three patients (n = 2243) received navigator outreach. LESSONS LEARNED: Implementing a multisite health system-wide ACP program and pragmatic trial, with automated EHR-based cohort identification and intervention delivery, requires a high level of multidisciplinary key advisor engagement, standardization, and monitoring. These activities provide guidance for the implementation of other large-scale, population-based ACP efforts.

BACKGROUND: Unanticipated changes in health status and worsening of chronic conditions often prompt the need to consider emergency general surgery (EGS). Although discussions about goals of care may promote goal-concordant care and reduce patient and caregiver depression and anxiety, these conversations, as well as standardized documentation, remain infrequent for EGS patients. METHODS: We conducted a retrospective cohort study using electronic health record data from patients admitted to an EGS service at a tertiary academic center to determine the prevalence of clinically meaningful advance care planning (ACP) documentation (conversations and legal ACP forms) during the EGS hospitalization. Multivariable regression was performed to identify patient, clinician, and procedural factors associated with the lack of ACP. RESULTS: Among 681 patients admitted to the EGS service in 2019, only 20.1% had ACP documentation in the electronic health record at any time point during their hospitalization (of those, 75.5% completed before and 24.5% completed during admission). Two thirds (65.8%) of the total cohort had surgery during their admission, but none of them had a documented ACP conversation with the surgical team preoperatively. Patients with ACP documentation tended to have Medicare insurance (adjusted odds ratio, 5.06; 95% confidence interval, 2.09-12.23; p < 0.001) and had greater burden of comorbid conditions (adjusted odds ratio, 4.19; 95% confidence interval, 2.55-6.88; p < 0.001). CONCLUSION: Adults experiencing a significant, often abrupt change in health status leading to an EGS admission are infrequently engaged in ACP conducted by the surgical team. This is a critical missed opportunity to promote patient-centered care and to communicate patients care preferences to the surgical and other inpatient medical teams. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

OBJECTIVE: Increased social risk data collection in health care settings presents new opportunities to apply this information to improve patient outcomes. Clinical decision support (CDS) tools can support these applications. We conducted a participatory engagement process to develop electronic health record (EHR)-based CDS tools to facilitate social risk-informed care plan adjustments in community health centers (CHCs). MATERIALS AND METHODS: We identified potential care plan adaptations through systematic reviews of hypertension and diabetes clinical guidelines. The results were used to inform an engagement process in which CHC staff and patients provided feedback on potential adjustments identified in the guideline reviews and on tool form and functions that could help CHC teams implement these suggested adjustments for patients with social risks. RESULTS: Partners universally prioritized tools for social risk screening and documentation. Additional high-priority content included adjusting medication costs and changing follow-up plans based on reported social risks. Most content recommendations reflected partners interests in encouraging provider-patient dialogue about care plan adaptations specific to patients social needs. Partners recommended CDS tool functions such as alerts and shortcuts to facilitate and efficiently document social risk-informed care plan adjustments. DISCUSSION AND CONCLUSION: CDS tools were designed to support CHC providers and staff to more consistently tailor care based on information about patients social context and thereby enhance patients ability to adhere to care plans. While such adjustments occur on an ad hoc basis in many care settings, these are among the first tools designed both to systematize and document these activities.

OBJECTIVES: Ambient clinical documentation technology uses automatic speech recognition (ASR) and natural language processing (NLP) to turn patient-clinician conversations into clinical documentation. It is a promising approach to reducing clinician burden and improving documentation quality. However, the performance of current-generation ASR remains inadequately validated. In this study, we investigated the impact of non-lexical conversational sounds (NLCS) on ASR performance. NLCS, such as Mm-hm and Uh-uh, are commonly used to convey important information in clinical conversations, for example, Mm-hm as a yes response from the patient to the clinician question are you allergic to antibiotics? MATERIALS AND METHODS: In this study, we evaluated 2 contemporary ASR engines, Google Speech-to-Text Clinical Conversation (Google ASR), and Amazon Transcribe Medical (Amazon ASR), both of which have their language models specifically tailored to clinical conversations. The empirical data used were from 36 primary care encounters. We conducted a series of quantitative and qualitative analyses to examine the word error rate (WER) and the potential impact of misrecognized NLCS on the quality of clinical documentation. RESULTS: Out of a total of 135 647 spoken words contained in the evaluation data, 3284 (2.4%) were NLCS. Among these NLCS, 76 (0.06% of total words, 2.3% of all NLCS) were used to convey clinically relevant information. The overall WER, of all spoken words, was 11.8% for Google ASR and 12.8% for Amazon ASR. However, both ASR engines demonstrated poor performance in recognizing NLCS: the WERs across frequently used NLCS were 40.8% (Google) and 57.2% (Amazon), respectively; and among the NLCS that conveyed clinically relevant information, 94.7% and 98.7%, respectively. DISCUSSION AND CONCLUSION: Current ASR solutions are not capable of properly recognizing NLCS, particularly those that convey clinically relevant information. Although the volume of NLCS in our evaluation data was very small (2.4% of the total corpus; and for NLCS that conveyed clinically relevant information: 0.06%), incorrect recognition of them could result in inaccuracies in clinical documentation and introduce new patient safety risks.

OBJECTIVE: We sought to understand the frequency of contraception documentation for women with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) in a large US electronic health record (EHR)-based registry and to identify disparities by teratogen prescription and patient race and ethnicity. METHODS: Contraception documentation from structured data fields within the Rheumatology Informatics System for Effectiveness (RISE) registry was collected for women of childbearing age (18-45 years) in 2018 who had at least 2 visits with International Classification of Diseases, Ninth Revision or Tenth Revision, diagnosis codes for SLE or RA (at any time). Univariate and multivariate analyses compared the frequency of contraception documentation based on patient characteristics including diagnosis, age, race, and teratogenicity of prescribed antirheumatic medications. RESULTS: In 2018, there were 9,826 women of childbearing age with SLE and 19,009 with RA, of whom 9.1% had any contraception documented. Rates of contraceptive documentation were significantly lower for women with SLE (adjusted odds ratio [OR] 0.84 [95% confidence interval (95% CI) 0.76-0.92]). Women of Hispanic ethnicity and Black and Asian race were all less likely than White women to have contraception documentation. Teratogen prescription was associated with higher rates of contraception documentation for women with RA but not SLE (RA adjusted OR 1.31 [95% CI 1.16-1.47]; SLE adjusted OR 1.08 [95% CI 0.91-1.28]). CONCLUSION: There are large gaps in contraception documentation within the RISE registry that are particularly stark among women of color. Although these data likely underestimate contraception use, they highlight that most rheumatologists do not have a systematic approach to collecting and recording this information in the EHR.

BACKGROUND: Asthma is the most common pediatric chronic disease; thus, clinical guidelines have been developed for its assessment and management, which rely on systematic symptom documentation. Electronic health records (EHR) have the potential to record clinical data systematically; however, variability in documentation persists. OBJECTIVE: To identify if the use of a structured asthma template is associated with increased guideline-based asthma documentation and clinical outcomes when compared with the use of nonstructured ones. METHODS: We performed a retrospective case-control study comparing the use of nonstructured templates (NSTs) and asthma-structured templates (ASTs) in new patient and first follow-up encounters, evaluated by pediatric pulmonologists between March 2016 and December 2021. Asthma history items were selected following clinical guidelines, summarized in 29 items for new and 22 items for follow-up encounters. Associations with demographic, spirometry, and health care utilization were explored. RESULTS: A total of 546 initial encounters were included; 450 used structured templates. The use of an AST was associated with higher documentation of asthma items in initial and follow-up encounters. Linear regression analysis showed that the use of ASTs was associated with a 28.2% and 39.65% increase in asthma history completeness (in initial and follow-up encounters, respectively), compared with the use of NSTs. AST use was associated with higher rates of systemic steroid prescriptions within 12 months. No other differences were observed after adjusting for asthma severity. CONCLUSIONS: Using asthma-specific structured templates was associated with increased guideline-based asthma documentation. Leveraging the EHR as a clinical and research tool has the potential to improve clinical practice.

OBJECTIVE: Electronic health records (EHRs) are increasingly used to capture social determinants of health (SDH) data, though there are few published studies of clinicians engagement with captured data and whether engagement influences health and healthcare utilization. We compared the relative frequency of clinician engagement with discrete SDH data to the frequency of engagement with other common types of medical history information using data from inpatient hospitalizations. MATERIALS AND METHODS: We created measures of data engagement capturing instances of data documentation (data added/updated) or review (review of data that were previously documented) during a hospitalization. We applied these measures to four domains of EHR data, (medical, family, behavioral, and SDH) and explored associations between data engagement and hospital readmission risk. RESULTS: SDH data engagement was associated with lower readmission risk. Yet, there were lower levels of SDH data engagement (8.37% of hospitalizations) than medical (12.48%), behavioral (17.77%), and family (14.42%) history data engagement. In hospitalizations where data were available from prior hospitalizations/outpatient encounters, a larger proportion of hospitalizations had SDH data engagement than other domains (72.60%). DISCUSSION: The goal of SDH data collection is to drive interventions to reduce social risk. Data on when and how clinical teams engage with SDH data should be used to inform informatics initiatives to address health and healthcare disparities. CONCLUSION: Overall levels of SDH data engagement were lower than those of common medical, behavioral, and family history data, suggesting opportunities to enhance clinician SDH data engagement to support social services referrals and quality measurement efforts.

BackgroundCommunity Advisory Boards (CABs) have been frequently used to engage diverse partners to inform research projects. Yet, evaluating the quality of engagement has not been routine. We describe a multi-method ethnographic approach documenting and assessing partner engagement in two "virtual" CABs, for which we conducted all meetings remotely.MethodsTwo research projects for increasing equitable COVID-19 testing, vaccination, and clinical trial participation for underserved communities involved remote CAB meetings. Thirty-three partners representing 17 community groups participated in 15 sessions across the two CABs facilitated by a social change organization. We developed ethnographic documentation forms to assess multiple aspects of CAB member engagement (e.g., time spent speaking, modality used, types of interactions). Documenters were trained to observe CAB sub-groups via virtual sessions. Debriefing with the documentation team after CAB meetings supported quality assurance and process refinement. CAB members completed a brief validated survey after each meeting to assess the quality and frequency of engagement. Content and rapid thematic analysis were used to analyze documentation data. Quantitative data were summarized as frequencies and means. Qualitative and quantitative findings were triangulated.ResultsA total of 4,540 interactions were identified across 15 meetings. The most frequent interaction was providing information (44%), followed by responding (37-38%). The quality and frequency of stakeholder engagement were rated favorably (average 4.7 of 5). Most CAB members (96%) reported good/excellent engagement. Specific comments included appreciation for the diversity of perspectives represented by the CAB members and suggestions for improved live interpretation. Debriefing sessions led to several methodological refinements for the documentation process and forms.ConclusionWe highlight key strategies for documenting and assessing community engagement. Our methods allowed for rich ethnographic data collection that refined our work with community partners. We recommend ongoing trainings, including debriefing sessions and routinely reviewed assessment of data to strengthen meaningful community engagement.

BackgroundIn recent years, Canadian provinces have been discussing, implementing, and tightening vaccination "mandate" policies for school enrolment. British Columbia (BC), Canada's westernmost province, implemented a Vaccination Status Reporting Regulation (VSRR) in September 2019, which requires the vaccination status of children in public, private, and home schooling be reported to a provincial vaccination registry and education for parents who refuse to vaccinate. Legal vaccination mandates can carry the risk of backlash, thereby making it important to monitor public attitudes across policy implementation windows. The present study aimed to evaluate public support for this new provincial mandate following implementation.MethodsAn online panel of BC adults (n = 1301) was surveyed about 15 vaccine-promotion policy options in April 2020 following mandate implementation. Respondents were representative of the provincial population by gender, age, geographic residence, and percentage of households with children younger than 19 years of age. Poisson regression was used to estimate predictors of policy endorsement, and support for the VSRR.ResultsStrong support existed for the VSRR with 88.2% of respondents agreeing or strongly agreeing that parents should be required to provide their children's immunization records at school entry, and 74.6% supporting required education sessions for parents who refuse to vaccinate their children. Overall, the sample was supportive of vaccination, and pro-vaccine attitudes were associated with strong agreement for nearly all vaccine policy options. Policies to impose rewards (e.g., tax credits) and penalties (e.g., fines) were the least likely to receive strong agreement from respondents.ConclusionsNear the end of the first school year in British Columbia subject to the Vaccination Status Reporting Regulation, support for both the mandated documentation and mandated education elements of the policy are high, and associated with pro-vaccine attitudes. There are not marked differences in strong support based on gender, age, parenting, education level, or income.

Healthcare organizations are increasing social determinants of health (SDH) screening and documentation in the electronic health record (EHR). Physicians may use SDH data for medical decision-making and to provide referrals to social care resources. Physicians must be aware of these data to use them, however, and little is known about physicians awareness of EHR-based SDH documentation or documentation capabilities. We therefore leveraged national physician survey data to measure level of awareness and variation by physician, practice, and EHR characteristics to inform practice- and policy-based efforts to drive medical-social care integration. We identify higher levels of social needs documentation awareness among physicians practicing in community health centers, those participating in payment models with social care initiatives, and those aware of other advanced EHR functionalities. Findings indicate that there are opportunities to improve physician education and training around new EHR-based SDH functionalities.

BackgroundDuring the COVID-19 pandemic, self-reported COVID-19 vaccination might facilitate rapid evaluations of vaccine effectiveness (VE) when source documentation (e.g., immunization information systems [IIS]) is not readily available. We evaluated the concordance of COVID-19 vaccination status ascertained by self-report versus source documentation and its impact on VE estimates.MethodsHospitalized adults (≥18 years) admitted to 18 U.S. medical centers March-June 2021 were enrolled, including COVID-19 cases and SARS-CoV-2 negative controls. Patients were interviewed about COVID-19 vaccination. Abstractors simultaneously searched IIS, medical records, and other sources for vaccination information. To compare vaccination status by self-report and documentation, we estimated percent agreement and unweighted kappa with 95% confidence intervals (CIs). We then calculated VE in preventing COVID-19 hospitalization of full vaccination (2 doses of mRNA product ≥14 days prior to illness onset) independently using data from self-report or source documentation.ResultsOf 2520 patients, 594 (24%) did not have self-reported vaccination information to assign vaccination group; these patients tended to be more severely ill. Among 1924 patients with both self-report and source documentation information, 95.0% (95% CI: 93.9-95.9%) agreement was observed, with a kappa of 0.9127 (95% CI: 0.9109-0.9145). VE was 86% (95% CI: 81-90%) by self-report data only and 85% (95% CI: 81-89%) by source documentation data only.ConclusionsApproximately one-quarter of hospitalized patients could not provide self-report COVID-19 vaccination status. Among patients with self-report information, there was high concordance with source documented status. Self-report may be a reasonable source of COVID-19 vaccination information for timely VE assessment for public health action.

OBJECTIVE: The authors describe a novel solution to the challenges of lengthy notes and poor note readability by creating an unobtrusive clinical decision support tool named disappearing help text. METHODS: We designed this tool in Pediatric Hospital Medicine (PHM) note templates to provide in-line decision support on best documentation practices, note bloat reduction, billing compliance, and provider workflow enhancement. RESULTS: After template changes that utilized disappearing help text, we reduced the percent of notes utilizing any laboratory SmartLink from 90.2 to 15.3% for admission notes (p

Restrictive policies and limited resources create challenges for care delivery for patients without documentation status (PWDS). This study explores the motivators and sustainers for healthcare providers serving PWDS. Twenty-four direct providers in public and private sectors were interviewed using semi-structured, in-depth interviews. Two members of the research team independently coded interviews using inductive thematic analysis. Four major themes emerged illustrating intrinsic and extrinsic sources that motivated and sustained providers: (1) a sense of calling to serve their community; (2) solidarity is sustaining; (3) organizational culture as a key element for provider engagement; (4) insight into necessary change. Providers who care for PWDS are driven and sustained by internal motivations and a sense of solidarity in working towards better care access for their marginalized patients. Findings illustrate the importance of recruiting and retaining providers with histories of recent migration. Immigration and healthcare policy reform may improve provider workflow.

Since 2017, the TrueNTH Global Registry (TNGR) has aimed to drive improvement in patient outcomes for individuals with localized prostate cancer by collating data from healthcare institutions across 13 countries. As TNGR matures, a systematic evaluation of existing processes and documents is necessary to evaluate whether the registry is operating as intended. The main supporting documents: protocol and data dictionary, were comprehensively reviewed in a series of meetings over a 10-month period by an international working group. In parallel, individual consultations with local institutions regarding a benchmarking quality-of-care report were conducted. Four consensus areas for improvement emerged: updating operational definitions, appraisal of the recruitment process, refinement of data elements, and improvement of data quality and reporting. Recommendations presented were drawn from our collective experience and accumulated knowledge in operating an international registry. These can be readily generalized to other health-related reporting programs beyond clinical registries.

BackgroundAdvance care planning allows patients to share their preferences for medical care with the aim of ensuring goal-concordant care in times of serious illness. The morbidity and mortality of the COVID-19 pandemic has increased the importance and public visibility of advance care planning. However, little is known about the frequency and quality of advance care planning documentation during the pandemic.AimThis study examined the frequency, quality, and predictors of advance care planning documentation among hospitalized medical patients with and without COVID-19.DesignThis retrospective cohort analysis used multivariate logistic regression to identify factors associated with advance care planning documentation.Setting/participantsThis study included all adult patients tested for COVID-19 and admitted to a tertiary medical center in San Francisco, CA during March 2020.ResultsAmong 262 patients, 31 (11.8%) tested positive and 231 (88.2%) tested negative for SARS-CoV-2. The rate of advance care planning documentation was 38.7% in patients with COVID-19 and 46.8% in patients without COVID-19 (p = 0.45). Documentation consistently addressed code status (100% and 94.4% for COVID-positive and COVID-negative, respectively), but less often named a surrogate decision maker, discussed prognosis, or elaborated on other wishes for care. Palliative care consultation was associated with increased advance care planning documentation (OR: 6.93, p = 0.004).ConclusionThis study found low rates of advance care planning documentation for patients both with and without COVID-19 during an evolving global pandemic. Advance care planning documentation was associated with palliative care consultation, highlighting the importance of such consultation to ensure timely, patient-centered advance care planning.

BACKGROUND: Longitudinal patient level data available in the electronic health record (EHR) allows for the development, implementation, and validations of dental quality measures (eMeasures). OBJECTIVE: We report the feasibility and validity of implementing two eMeasures. The eMeasures determined the proportion of patients receiving a caries risk assessment (eCRA) and corresponding appropriate risk-based preventative treatments for patients at elevated risk of caries (appropriateness of care [eAoC]) in two academic institutions and one accountable care organization, in the 2019 reporting year. METHODS: Both eMeasures define the numerator and denominator beginning at the patient level, populations specifications, and validated the automated queries. For eCRA, patients who completed a comprehensive or periodic oral evaluation formed the denominator, and patients of any age who received a CRA formed the numerator. The eAoC evaluated the proportion of patients at elevated caries risk who received the corresponding appropriate risk-based preventative treatments. RESULTS: EHR automated queries identified in three sites 269,536 patients who met the inclusion criteria for receiving a CRA. The overall proportion of patients who received a CRA was 94.4% (eCRA). In eAoC, patients at elevated caries risk levels (moderate, high, or extreme) received fluoride preventive treatment ranging from 56 to 93.8%. For patients at high and extreme risk, antimicrobials were prescribed more frequently site 3 (80.6%) than sites 2 (16.7%) and 1 (2.9%). CONCLUSION: Patient-level data available in the EHRs can be used to implement process-of-care dental eCRA and AoC, eAoC measures identify gaps in clinical practice. EHR-based measures can be useful in improving delivery of evidence-based preventative treatments to reduce risk, prevent tooth decay, and improve oral health.

One promising solution to address physician data entry needs is through the development of so-called "digital scribes," or tools which aim to automate clinical documentation via automatic speech recognition (ASR) of patient-clinician conversations. Evaluation of specialized ASR models in this domain, useful for understanding feasibility and development opportunities, has been difficult because most models have been under development. Following the commercial release of such models, we report an independent evaluation of four models, two general-purpose, and two for medical conversation with a corpus of 36 primary care conversations. We identify word error rates (WER) of 8.8%-10.5% and word-level diarization error rates (WDER) ranging from 1.8%-13.9%, which are generally lower than previous reports. The findings indicate that, while there is room for improvement, the performance of these specialized models, at least under ideal recording conditions, may be amenable to the development of downstream applications which rely on ASR of patient-clinician conversations.

ObjectiveElectronic Health Records (EHRs) increasingly include designated fields to capture social determinants of health (SDOH). We developed measures to characterize their use, and use of other SDOH data types, to optimize SDOH data integration.Materials and methodsWe developed 3 measures that accommodate different EHR data types on an encounter or patient-year basis. We implemented these measures-documented during encounter (DDE) captures documentation occurring during the encounter; documented by discharge (DBD) includes DDE plus documentation occurring any time prior to admission; and reviewed during encounter (RDE) captures whether anyone reviewed documented data-for the newly available structured SDOH fields and 4 other comparator SDOH data types (problem list, inpatient nursing question, social history free text, and social work notes) on a hospital encounter basis (with patient-year metrics in the Supplementary Appendix). Our sample included all patients (n = 27 127) with at least one hospitalization at UCSF Health (a large, urban, tertiary medical center) over a 1-year period.ResultsWe observed substantial variation in the use of different SDOH EHR data types. Notably, social history question fields (newly added at study period start) were rarely used (DDE: 0.03% of encounters, DBD: 0.26%, RDE: 0.03%). Free-text patient social history fields had higher use (DDE: 12.1%, DBD: 49.0%, RDE: 14.4%).DiscussionOur measures of real-world SDOH data use can guide current efforts to capture and leverage these data. For our institution, measures revealed substantial variation across data types, suggesting the need to engage in efforts such as EHR-user education and targeted workflow integration.ConclusionMeasures revealed opportunities to optimize SDOH data documentation and review.

BackgroundDetecting delirium with standardized assessment tools such as the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is important, but such detection is frequently hampered by poor documentation and inappropriate "unable to assess" responses (in noncomatose patients).ObjectiveTo identify patient, clinical, and workplace factors that may impede or facilitate appropriate delirium assessment through use of the CAM-ICU, specifically documentation and inappropriate "unable to assess" responses.MethodsAn electronic health record-based data set was used to quantify CAM-ICU documentation and inappropriate "unable to assess" responses during 24 months. Associated patient (eg, age), clinical (eg, diagnosis), and workplace (eg, geographic location within the ICU, shift) factors were evaluated with multivariable regression.ResultsOf 28 586 CAM-ICU documentation opportunities, 66% were documented; 16% of documentations in alert or lightly sedated patients had inappropriate "unable to assess" responses. Night shift was associated with lower CAM-ICU documentation rates (P = .001), whereas physical restraints and location on side B (rather than side A) of the ICU were associated with higher documentation rates (P < .05 for both). Age older than 80 years, non-White race, intubation, and physical restraints were associated with more inappropriate "unable to assess" responses (all P < .05), as was infusion of propofol, midazolam, dexmedetomidine, or fentanyl (all P < .05).ConclusionData from electronic health records can identify patient, clinical, and workplace factors associated with CAM-ICU documentation and inappropriate "unable to assess" responses, which can help target quality improvement efforts related to delirium assessment.

BackgroundThe reasons for discordance between advance care planning (ACP) documentation and current preferences are not well understood. The POLST form offers a unique opportunity to learn about the reasons for discordance and concordance that has relevance for POLST as well as ACP generally.DesignQualitative descriptive including constant comparative analysis within and across cases.SettingTwenty-six nursing facilities in Indiana.ParticipantsResidents (n = 36) and surrogate decision-makers of residents without decisional capacity (n = 37).MeasurementsA semi-structured interview guide was used to explore the reasons for discordance or concordance between current preferences and existing POLST forms.FindingsReasons for discordance include: (1) problematic nursing facility practices related to POLST completion; (2) missing key information about POLST treatment decisions; (3) deferring to others; and (4) changes over time. Some participants were unable to explain the discordance due to a lack of insight or inability to remember details of the original POLST conversation. Explanations for concordance include: (1) no change in the resident's medical condition and/or the resident is unlikely to improve; (2) use of the substituted judgment standard for surrogate decision-making; and (3) fixed opinion about what is "right" with little to no insight.ConclusionParticipant explanations for discordance between existing POLST orders and current preferences highlight the importance of adequate structures and processes to support high quality ACP in nursing facilities. Residents with stable or poor health may be more appropriate candidates for POLST than residents with a less clear prognosis, though preferences should be revisited periodically as well as when there is a change in condition to help ensure existing documentation is concordant with current treatment preferences.

ObjectiveTo describe the development of the Pediatric Epilepsy Outcome-Informatics Project (PEOIP) at Alberta Children's Hospital (ACH), which was created to provide standardized, point-of-care data entry; near-time data analysis; and availability of outcome dashboards as a baseline on which to pursue quality improvement.MethodsStakeholders involved in the PEOIP met weekly to determine the most important outcomes for patients diagnosed with epilepsy, create a standardized electronic note with defined fields (patient demographics, seizure and syndrome type and frequency and specific outcomes- seizure type and frequency, adverse effects, emergency department visits, hospitalization, and care pathways for clinical decision support. These were embedded in the electronic health record from which the fields were extracted into a data display platform that provided patient- and population-level dashboards updated every 36 hours. Provider satisfaction and family experience surveys were performed to assess the impact of the standardized electronic note.ResultsIn the last 5 years, 3,245 unique patients involving 13, 831 encounters had prospective, longitudinal, standardized epilepsy data accrued via point-of-care data entry into an electronic note as part of routine clinical care. A provider satisfaction survey of the small number of users involved indicated that the vast majority believed that the note makes documentation more efficient. A family experience survey indicated that being provided with the note was considered "valuable" or "really valuable" by 86% of respondents and facilitated communication with family members, school, and advocacy organizations.SignificanceThe PEOIP serves as a proof of principle that information obtained as part of routine clinical care can be collected in a prospective, standardized, efficient manner and be used to construct filterable process/outcome dashboards, updated in near time (36 hours). This information will provide the necessary baseline data on which multiple of QI projects to improve meaningful outcomes for children with epilepsy will be based.

BACKGROUND: Our objective was to measure the proportion of patients for which comprehensive periodontal charting, periodontal disease risk factors (diabetes status, tobacco use, and oral home care compliance), and periodontal diagnoses were documented in the electronic health record (EHR). We developed an EHR-based quality measure to assess how well four dental institutions documented periodontal disease-related information. An automated database script was developed and implemented in the EHR at each institution. The measure was validated by comparing the findings from the measure with a manual review of charts. RESULTS: The overall measure scores varied significantly across the four institutions (institution 1 = 20.47%, institution 2 = 0.97%, institution 3 = 22.27% institution 4 = 99.49%, p-value  80%). CONCLUSION: Our results demonstrate the feasibility of developing automated data extraction scripts using structured data from EHRs, and successfully implementing these to identify and measure the periodontal documentation completeness within and across different dental institutions.

BACKGROUND: Patients with end-stage liver disease awaiting liver transplantation (LT) are seriously ill and experience fluctuating periods of clinical decompensation. Discussion of a patients advance care planning (ACP) wishes early in their dynamic disease course is critical to providing value-aligned care while awaiting LT. We aimed to evaluate current ACP documentation and assess readiness to engage in ACP in this population. METHODS: We conducted a retrospective study of adults undergoing LT evaluation from January 2017 to June 2017 and assessed characteristics associated with documentation using logistic regression. We then administered a survey to LT candidates from March 2018 to May 2018 to determine self-reported readiness to engage in ACP (range 1 = not at all ready to 5 = very ready). RESULTS: Among 170 LT candidates, median (interquartile range) age was 58 (53-65), 65% were men, MELDNa was 15 (11-21), and Child-Pugh A/B/C were 33/38/29%. Nine percent reported completing ACP prior to LT evaluation, but 0% had legal ACP forms or end-of-life wishes documented in the medical record. A durable power of attorney (DPOA) was discussed with 10%. In univariable analysis, white race (OR 4.16, p = 0.03) and female sex (OR 3.06, p = 0.04) were associated with ACP documentation, but Child-Pugh score and MELDNa were not. Of the 41 LT candidates who completed the ACP survey, 93% were ready to appoint a DPOA and 85% were ready to discuss end-of-life care. CONCLUSION: There is a paucity of ACP documentation and identification of DPOA among LT candidates, despite patients reporting readiness to complete ACP and appoint a DPOA. These results reveal an opportunity for tools to facilitate discussions around ACP between clinicians, patients, and their caregivers.

BackgroundPatients with end-stage liver disease awaiting liver transplantation (LT) are seriously ill and experience fluctuating periods of clinical decompensation. Discussion of a patient's advance care planning (ACP) wishes early in their dynamic disease course is critical to providing value-aligned care while awaiting LT. We aimed to evaluate current ACP documentation and assess readiness to engage in ACP in this population.MethodsWe conducted a retrospective study of adults undergoing LT evaluation from January 2017 to June 2017 and assessed characteristics associated with documentation using logistic regression. We then administered a survey to LT candidates from March 2018 to May 2018 to determine self-reported readiness to engage in ACP (range 1 = not at all ready to 5 = very ready).ResultsAmong 170 LT candidates, median (interquartile range) age was 58 (53-65), 65% were men, MELDNa was 15 (11-21), and Child-Pugh A/B/C were 33/38/29%. Nine percent reported completing ACP prior to LT evaluation, but 0% had legal ACP forms or end-of-life wishes documented in the medical record. A durable power of attorney (DPOA) was discussed with 10%. In univariable analysis, white race (OR 4.16, p = 0.03) and female sex (OR 3.06, p = 0.04) were associated with ACP documentation, but Child-Pugh score and MELDNa were not. Of the 41 LT candidates who completed the ACP survey, 93% were ready to appoint a DPOA and 85% were ready to discuss end-of-life care.ConclusionThere is a paucity of ACP documentation and identification of DPOA among LT candidates, despite patients reporting readiness to complete ACP and appoint a DPOA. These results reveal an opportunity for tools to facilitate discussions around ACP between clinicians, patients, and their caregivers.

ObjectivesTo understand how medical scribes' work may contribute to alleviating clinician burnout attributable directly or indirectly to the use of health IT.Materials and methodsQualitative analysis of semistructured interviews with 32 participants who had scribing experience in a variety of clinical settings.ResultsWe identified 7 categories of clinical tasks that clinicians commonly choose to offload to medical scribes, many of which involve delegated use of health IT. These range from notes-taking and computerized data entry to foraging, assembling, and tracking information scattered across multiple clinical information systems. Some common characteristics shared among these tasks include: (1) time-consuming to perform; (2) difficult to remember or keep track of; (3) disruptive to clinical workflow, clinicians' cognitive processes, or patient-provider interactions; (4) perceived to be low-skill "clerical" work; and (5) deemed as adding no value to direct patient care.DiscussionThe fact that clinicians opt to "outsource" certain clinical tasks to medical scribes is a strong indication that performing these tasks is not perceived to be the best use of their time. Given that a vast majority of healthcare practices in the US do not have the luxury of affording medical scribes, the burden would inevitably fall onto clinicians' shoulders, which could be a major source for clinician burnout.ConclusionsMedical scribes help to offload a substantial amount of burden from clinicians-particularly with tasks that involve onerous interactions with health IT. Developing a better understanding of medical scribes' work provides useful insights into the sources of clinician burnout and potential solutions to it.

This study examined if preclerkship medical students would find it educational to scribe in a pediatric setting. Scribing promoted students' learning about pediatric clinical encounters enhanced their competency with electronic health record use, and moderately reduced attending physician documentation burden.

Use of Electronic Nicotine Delivery Systems (ENDS, colloquially known as "electronic cigarettes") has increased substantially in the United States in the decade since 2010. However, currently relatively little is known regarding the documentation of ENDS use in clinical notes. With this study, we describe the development of an annotation scheme (and associated annotated corpus) consisting of 4,351 ENDS mentions derived from Department of Veterans Affairs clinical notes during the period 2010-2020. Analysis of our corpus provides important insights into ENDS documentation practices at the VA, in addition to providing a resource for the future development and validation of Natural Language Processing algorithms capable of reliably identifying ENDS-use status.

BACKGROUND: Multiple barriers exist for appropriate use of the proprotein convertase subtilisin/kexin type 9 enzyme inhibitors (PCSK9i) in patients with atherosclerotic cardiovascular disease (ASCVD) or familial hypercholesterolemia (FH) with inadequately controlled hypercholesterolemia despite standard therapies. Among these barriers, high payer rejection rates and inadequate prior authorization (PA) documentation by providers hinder optimal use of PCSK9i. OBJECTIVES: To (a) identify and discuss provider and payer discordances on barriers to authorization and use of PCSK9i based on clinical and real-world evidence and (b) align understanding and application of clinical, cost, safety, and efficacy data of PCSK9i. METHODS: Local groups of 3 payers and 3 providers met in 6 separate locations across the United States through a collaborative project of AMCP and PRIME Education. Responses to selected pre- and postmeeting survey questions measured changes in attitudes and beliefs regarding treatment barriers, lipid thresholds for considering PCSK9i therapy, and tactics for improving PA processes. Statistical analysis of inter- and intragroup changes in attitudes were performed by Cox proportional hazards test and Fishers exact test for < 5 variables. RESULTS: The majority of providers and payers (67%-78%) agreed that high patient copayments and inadequate PA documentation were significant barriers to PCSK9i usage. However, payers and providers differed on beliefs that current evidence does not support PCSK9i cost-effectiveness (6% providers, 56% payers; P = 0.003) and that PA presents excessive administrative burden (72% providers, 44% payers; P = 0.09) Average increases pre- to postmeeting were noted in provider beliefs that properly documented PA forms expedite access to PCSK9i (22%-50% increase) and current authorization criteria accurately distinguish patients who benefit most from PCSK9i (6%-22%). Payers decreased in their belief that current authorization criteria accurately distinguish benefiting patients (72%-50%). Providers and payers increased in their belief that PCSK9i are cost-effective (44%-61% and 28%-50%, respectively) and were more willing to consider PCSK9i at the low-density lipoprotein cholesterol threshold of > 70 mg/dL for patients with ASCVD (78%-83% and 44%-67%, respectively) or FH (22%-39% and 22%-33%). Payers were more agreeable to less stringent PA requirements for patients with FH (33%-72%, P = 0.019) and need for standardized PA requirements (50%-83%, P = 0.034); these considerations remained high (89%) among providers after the meeting. Most participants supported educational programs for patient treatment adherence (83%) and physician/staff PA processes (83%-94%). CONCLUSIONS: Provider and payer representatives in 6 distinct geographic locations provided recommendations to improve quality of care in patients eligible for PCSK9i. Participants also provided tactical recommendations for streamlining PA documentation processes and improving awareness of PCSK9i cost-effectiveness and clinical efficacy. The majority of participants supported development of universal, standardized patient eligibility criteria and PA forms. DISCLOSURES: The study reported in this article was part of a continuing education program funded by an independent educational grant awarded by Sanofi US and Regeneron Pharmaceuticals to PRIME Education. The grantor had no role in the study design, execution, analysis, or reporting. AMCP received grant funding from PRIME to assist in the study, as well as in writing the manuscript. McCormick, Bhatt, Bays, Taub, Caldwell, Guerin, Steinhoff, and Ahmad received an honorarium from PRIME for serving as faculty for the continuing education program. McCormick, Bhatt, Bays, Taub, Caldwell, Guerin, Steinhoff, and Ahmad were involved as participants in the study. Bhatt discloses the following relationships: Advisory board: Cardax, CellProthera, Cereno Scientific, Elsevier Practice Update Cardiology, Level Ex, Medscape Cardiology, PhaseBio, PLx Pharma, Regado Biosciences; Board of directors: Boston VA Research Institute, Society of Cardiovascular Patient Care, TobeSoft; Chair: American Heart Association Quality Oversight Committee; Data monitoring committees: Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), Cleveland Clinic (including for the ExCEED trial, funded by Edwards), Contego Medical (Chair, PERFORMANCE 2), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for the ENVISAGE trial, funded by Daiichi Sankyo), Population Health Research Institute; Honoraria: American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org; Vice chair, ACC Accreditation Committee), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee funded by Boehringer Ingelheim; AEGIS-II executive committee funded by CSL Behring), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees, including for the PRONOUNCE trial, funded by Ferring Pharmaceuticals), HMP Global (Editor in Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), K2P (Co-Chair, interdisciplinary curriculum), Level Ex, Medtelligence/ReachMD (CME steering committees), MJH Life Sciences, Population Health Research Institute (for the COMPASS operations committee, publications committee, steering committee, and USA national co-leader, funded by Bayer), Slack Publications (Chief Medical Editor, Cardiology Todays Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), WebMD (CME steering committees); Other: Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Chair), VA CART Research and Publications Committee (Chair); Research funding: Abbott, Afimmune, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Cardax, Chiesi, CSL Behring, Eisai, Ethicon, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, Idorsia, Ironwood, Ischemix, Lexicon, Lilly, Medtronic, Pfizer, PhaseBio, PLx Pharma, Regeneron, Roche, Sanofi Aventis, Synaptic, The Medicines Company; Royalties: Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwalds Heart Disease); Site co-investigator: Biotronik, Boston Scientific, CSI, St. Jude Medical (now Abbott), Svelte; Trustee: American College of Cardiology; Unfunded research: FlowCo, Merck, Novo Nordisk, Takeda. Bays research site has received research grants from 89Bio, Acasti, Akcea, Allergan, Alon Medtech/Epitomee, Amarin, Amgen, AstraZeneca, Axsome, Boehringer Ingelheim, Civi, Eli Lilly, Esperion, Evidera, Gan and Lee, Home Access, Janssen, Johnson and Johnson, Lexicon, Matinas, Merck, Metavant, Novartis, Novo Nordisk, Pfizer, Regeneron, Sanofi, Selecta, TIMI, and Urovant. Bays has served as a consultant/advisor for 89Bio, Amarin, Esperion, Matinas, and Gelesis, and speaker for Esperion. McCormick, Caldwell, Guerin, Ahmad, Singh, Moreo, Carter, Heggen, and Sapir have nothing to disclose.

BackgroundHeart failure is a common and devastating complication of type 2 diabetes (T2D). Prompt recognition of heart failure may avert hospitalization, facilitate use of guideline-directed therapies, and impact choice of T2D medications. We sought to determine the rate and factors associated with heart failure documentation in T2D patients with evidence of volume overload requiring loop diuretics.MethodsDCR is an on-going, prospective US registry of outpatient T2D patients from > 5000 cardiology, endocrinology, and primary care clinicians (current analysis used data from 2013-2019). Among T2D patients receiving loop diuretics, we examined the rate of chart documentation of heart failure. We used a 3-level hierarchical logistic regression model (patients nested within physician within practice) to examine factors associated with heart failure diagnosis.ResultsAmong 1,322,640 adults with T2D, 225,125 (17.0%) were receiving a loop diuretic, of whom 91,969 (40.9%) had documentation of heart failure. Male sex, lower body mass index, atrial fibrillation, chronic kidney disease, and coronary artery disease were associated with greater odds of heart failure diagnosis. After accounting for patient factors, patients seen by cardiologists were the most likely to have HF documented followed by PCPs and then endocrinologists.ConclusionsAmong US outpatients with T2D, 17% of patients had evidence of volume overload-defined by loop diuretic prescription-of whom fewer than half had a clinical diagnosis of heart failure. While there may be non-heart failure indications for loop diuretics, our data suggest that a substantial proportion of T2D patients may have unrecognized heart failure and therefore could be missing opportunities for targeted therapies that could alter the clinical course of heart failure.

BackgroundIn Tanzania, there is no national trauma registry. The World Health Organization (WHO) has developed a data set for injury that specifies the variables necessary for documenting the burden of injury and patient-related clinical processes. As a first step in developing and implementing a national Trauma Registry, we determined how well hospitals currently capture the variables that are specified in the WHO injury set.MethodsThis was a prospective, observational cross-sectional study of all trauma patients conducted in the Emergency Units of five regional referral hospitals in Tanzania from February 2018 to July 2018. Research assistants observed the provision of clinical care in the EU for all patients, and documented performed assessment, clinical interventions and final disposition. Research assistants used a purposefully designed case report form to audit the injury variable capture rate, and to review Ministry of Health (MoH) issued facility Register book recording the documentation of variables. We present descriptive statistics for hospital characteristics, patient volume, facility infrastructure, and capture rate of trauma variables.ResultsDuring the study period, 2891 (9.3%) patients presented with trauma-related complaints, 70.7% were male. Overall, the capture rate of all variables was 33.6%. Documentation was most complete for demographics 71.6%, while initial clinical condition, and details of injury were documented in 20.5 and 20.8% respectively. There was no documentation for the care prior to Emergency Unit arrival in all hospitals. 1430 (49.5%) of all trauma-related visits seen were documented in the facility Health Management Information System register submitted to the MoH. Among the cases reported in the register book, the date of EU care was correctly documented in 77% cases, age 43.6%, diagnosis 66.7%, and outcome in 38.9% cases. Among the observed procedures, initial clinical condition (28.7%), interventions at Emergency Unit (52.1%), investigations (49.0%), and disposition (62.9%) were documented in the clinical charts.ConclusionsIn the regional hospitals of Tanzania, there is inadequate documentation of the minimum trauma variables specified in the WHO injury data set. Reasons for this are unclear, but will need to be addressed in order to improve documentation to inform a national injury registry.

BackgroundGroup visits can support health behavior change and self-efficacy. In primary care, an advance care planning (ACP) group visit may leverage group dynamics and peer mentorship to facilitate education and personal goal setting that result in ACP engagement.ObjectiveTo determine whether the ENgaging in Advance Care Planning Talks (ENACT) group visits intervention improves ACP documentation and readiness in older adults.MethodsThis randomized clinical trial was conducted among geriatric primary care patients from the University of Colorado Hospital Seniors Clinic, Aurora, CO, from August 2017 to November 2019. Participants randomized to ENACT group visits (n = 55) participated in two 2-hour sessions with discussions of ACP topics and use of ACP tools (i.e., Conversation Starter Kit, Medical Durable Power of Attorney form, and PREPARE videos). Participants randomized to the control arm (n = 55) received the Conversation Starter Kit and a Medical Durable Power of Attorney form by mail. The primary outcomes included presence of ACP documents or medical decision-maker documentation in the electronic health record (EHR) at 6 months, and a secondary outcome was ACP readiness (validated four-item ACP Engagement Survey) at 6 months.ResultsParticipants were a mean of 77 years old, 60% female, and 79% white. At 6 months, 71% of ENACT participants had an advance directive in the EHR (26% higher) compared with 45% of control arm participants (P

Background/objectivesA patient-directed, online program (PREPARE for Your Care [PREPARE]; prepareforyourcare.org) has been shown to increase advance care planning (ACP) documentation. However, the mechanisms underlying PREPARE are unknown. Our objectives were to compare the efficacy of PREPARE plus an easy-to-read advance directive (AD) vs an AD alone to increase active patient participation in ACP discussions during clinic visits and to examine effects of active patient participation on ACP documentation.DesignAudio recordings of postintervention primary care visits from two randomized trials (2013-2016).SettingSeven primary care clinics at a veterans affair and safety-net hospital in San Francisco, CA.ParticipantsEnglish- and Spanish-speaking adults, aged 55 years and older, with two or more chronic/serious conditions.InterventionPREPARE plus an easy-to-read AD or an AD alone.MeasurementsThe primary outcome was the number of active patient participation utterances about ACP (eg, asking questions, stating preferences) measured by the validated Active Patient Participation Coding Scheme. We examined differences in utterances by study arm using mixed effects negative binomial models and utterances as a mediator of PREPARE's effect on documentation using adjusted logistic regression. Models were adjusted for health literacy, prior care planning, and clinician.ResultsAmong 393 participants, the mean (SD) age was 66 (8.1) years, 120 (30.5%) had limited health literacy, and 99 (25.2%) were Spanish speaking. PREPARE plus the AD resulted in 41% more active patient participation in ACP discussions compared with the AD alone (mean [SD] = 10.1 [16.8] vs 6.6 [13.4] utterances; incidence rate ratio = 1.41; 95% confidence interval = 1.00-1.98). For every additional utterance, participants had 15% higher odds of ACP documentation, and active patient participation accounted for 16% of PREPARE's effect on documentation.ConclusionsThe PREPARE program and easy-to-read AD empowered patients to actively participate in ACP discussions during clinical visits more than the AD alone. Increased activation was associated with increased ACP documentation. Therefore, PREPARE may mitigate barriers to ACP among English- and Spanish-speaking older adults.Trial registrationClinicalTrials.gov identifiers: "Improving Advance Care Planning by Preparing Diverse Seniors for Decision Making (PREPARE)" NCT01990235 and "Preparing Spanish-Speaking Older Adults for Advance Care Planning and Medical Decision Making (PREPARE)" NCT02072941. J Am Geriatr Soc 68:1210-1217, 2020.

ObjectivesThe acute respiratory distress syndrome is common in critically ill patients. Recognition is crucial because acute respiratory distress syndrome is associated with a high mortality rate, and low tidal volume ventilation improves mortality. However, acute respiratory distress syndrome often goes unrecognized. Risk factors for under-recognition and trends over time have not been fully described.DesignRetrospective chart review of patients with acute respiratory distress syndrome from a prospective cohort study of critically ill patients. For each patient's ICU stay, we searched the chart for terms that indicated that acute respiratory distress syndrome was diagnosed, in the differential diagnosis, or treated with low tidal volume ventilation.SettingICUs at a tertiary hospital at the University of California, San Francisco between 2008 and 2016.PatientsCritically ill patients with acute respiratory distress syndrome.InterventionsNone.Measurements and main resultsAcute respiratory distress syndrome was recognized in 70% of patients, and recognition increased from 60% in 2008-2009 to 92% in 2016 (p = 0.004). Use of tidal volumes less than 6.5 mL/kg also increased (p < 0.001) from 20% to 92%. Increased acute respiratory distress syndrome severity (p = 0.01) and vasopressor use (p = 0.04) were associated with greater recognition. Clinician diagnosis of acute respiratory distress syndrome and inclusion of acute respiratory distress syndrome in the differential diagnosis were associated with tidal volumes less than 6.5 mL/kg (51% use of tidal volume ≤ 6.5 mL/kg if acute respiratory distress syndrome recognized vs 15% if not recognized; p = 0.002). Diagnosing acute respiratory distress syndrome was associated with lower tidal volume in multivariate analysis.ConclusionsAlthough acute respiratory distress syndrome recognition and low tidal volume ventilation use have increased over time, they remain less than universal. Clinician recognition of acute respiratory distress syndrome is associated with both systemic and respiratory severity of illness and is also associated with use of low tidal volume ventilation.

PurposeDespite increasing electronic health record (EHR) adoption, perceptions of EHRs are negative among ophthalmologists due to concerns about productivity, costs, and documentation. The authors evaluated the effects of EHR adoption in an oculoplastics practice, which had not been previously studied.MethodsClinical volume, documentation time, time spent with patients, reimbursement, relative value units, and patient satisfaction were examined for 2 academic oculoplastics attendings between April 2018 and April 2019, with EHR implementation in September 2018.ResultsThe mean number of patients seen in a half-day clinic was 31.8 versus 27.7 (p = 0.018) pre- and post-EHR implementation, respectively. EHR implementation had no effect on total monthly reimbursement (p = 0.88) or total monthly relative value units (p = 0.54). Average reimbursement (p = 0.004) and relative value units (p = 0.001) per patient encounter were significantly greater with EHR use. Patient satisfaction scores improved (p = 0.018). Mean physician time per patient increased from 6.4 to 9.0 minutes (p < 0.001). Mean documentation time per patient increased from 1.7 to 3.6 minutes (p < 0.001). Average patient wait times decreased by 9 minutes (p = 0.03) with EHR use. No scribes were used.ConclusionsEHR implementation was associated with decreased patient volume without significant differences in total reimbursement. Although EHR adoption was associated with increased physician time devoted to patients and greater time expenditure on documentation, patients experienced decreased wait times. This suggests that EHR use streamlined the overall clinic flow without sacrificing physicians' time with the patient. The author's findings suggest that EHR implementation can be accomplished in an academic oculoplastics setting without negative impact on patient experience or reimbursement considerations.

OBJECTIVE: Use of medical scribes reduces clinician burnout by sharing the burden of clinical documentation. However, medical scribes are cost-prohibitive for most settings, prompting a growing interest in developing ambient, speech-based technologies capable of automatically generating clinical documentation based on patient-provider conversation. Through a systematic review, we aimed to develop a thorough understanding of the work performed by medical scribes in order to inform the design of such technologies. MATERIALS AND METHODS: Relevant articles retrieved by searching in multiple literature databases. We conducted the screening process following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) in guidelines, and then analyzed the data using qualitative methods to identify recurring themes. RESULTS: The literature search returned 854 results, 65 of which met the inclusion criteria. We found that there is significant variation in scribe expectations and responsibilities across healthcare organizations; scribes also frequently adapt their work based on the providers style and preferences. Further, scribes job extends far beyond capturing conversation in the exam room; they also actively interact with patients and the care team and integrate data from other sources such as prior charts and lab test results. DISCUSSION: The results of this study provide several implications for designing technologies that can generate clinical documentation based on naturalistic conversations taking place in the exam room. First, a one-size-fits-all solution will be unlikely to work because of the significant variation in scribe work. Second, technology designers need to be aware of the limited role that their solution can fulfill. Third, to produce comprehensive clinical documentation, such technologies will likely have to incorporate information beyond the exam room conversation. Finally, issues of patient consent and privacy have yet to be adequately addressed, which could become paramount barriers to implementing such technologies in realistic clinical settings. CONCLUSIONS: Medical scribes perform complex and delicate work. Further research is needed to better understand their roles in a clinical setting in order to inform the development of speech-based clinical documentation technologies.

ObjectiveUse of medical scribes reduces clinician burnout by sharing the burden of clinical documentation. However, medical scribes are cost-prohibitive for most settings, prompting a growing interest in developing ambient, speech-based technologies capable of automatically generating clinical documentation based on patient-provider conversation. Through a systematic review, we aimed to develop a thorough understanding of the work performed by medical scribes in order to inform the design of such technologies.Materials and methodsRelevant articles retrieved by searching in multiple literature databases. We conducted the screening process following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) in guidelines, and then analyzed the data using qualitative methods to identify recurring themes.ResultsThe literature search returned 854 results, 65 of which met the inclusion criteria. We found that there is significant variation in scribe expectations and responsibilities across healthcare organizations; scribes also frequently adapt their work based on the provider's style and preferences. Further, scribes' job extends far beyond capturing conversation in the exam room; they also actively interact with patients and the care team and integrate data from other sources such as prior charts and lab test results.DiscussionThe results of this study provide several implications for designing technologies that can generate clinical documentation based on naturalistic conversations taking place in the exam room. First, a one-size-fits-all solution will be unlikely to work because of the significant variation in scribe work. Second, technology designers need to be aware of the limited role that their solution can fulfill. Third, to produce comprehensive clinical documentation, such technologies will likely have to incorporate information beyond the exam room conversation. Finally, issues of patient consent and privacy have yet to be adequately addressed, which could become paramount barriers to implementing such technologies in realistic clinical settings.ConclusionsMedical scribes perform complex and delicate work. Further research is needed to better understand their roles in a clinical setting in order to inform the development of speech-based clinical documentation technologies.

Electronic health record (EHR) log data have shown promise in measuring physician time spent on clinical activities, contributing to deeper understanding and further optimization of the clinical environment. In this article, we propose 7 core measures of EHR use that reflect multiple dimensions of practice efficiency: total EHR time, work outside of work, time on documentation, time on prescriptions, inbox time, teamwork for orders, and an aspirational measure for the amount of undivided attention patients receive from their physicians during an encounter, undivided attention. We also illustrate sample use cases for these measures for multiple stakeholders. Finally, standardization of EHR log data measure specifications, as outlined here, will foster cross-study synthesis and comparative research.

BackgroundIncidental findings (IFs) are common among injured patients and create a complex problem with no standardized solution.Materials and methodsThis is a retrospective review of adult trauma patients admitted to a level I trauma center from January to May 2017. IFs from abdominal, chest, and neck imaging were categorized based on previously published guidelines focused on clinically significant IFs. Patient demographics related to access to care were collected. Outcome measures included documentation and patient notification of IFs. A univariate analysis was performed to identify characteristics that were associated with these outcomes.ResultsOf 1671 patients, 682 met inclusion criteria, and 418 (61.3%) had any IF based on the a priori categorization scheme. In total, 67 (9.8%) were homeless, 58 (8.5%) had no health insurance, and 115 (16.9%) had no established primary care provider prior to admission. Documentation of IFs was included in discharge summaries and instructions 76.5% and 40.2% of the time, respectively. Physicians were statistically more likely to appropriately document IFs when radiologists provided specific recommendations. Transfer to another hospital service prior to discharge and discharge to another acute care facility were associated with reduced rates of successful documentation. No factors significantly affected documentation of patient notification.ConclusionsTrauma patients are at risk for poor access to follow-up care of IFs. Expanding IF-specific guidelines, collaborating with radiologists to facilitate their inclusion in reports, and ensuring that IFs are part of patient hand-offs could provide systematic methods of improving their documentation.

Background and Purpose- The prehospital setting is a promising site for therapeutic intervention in stroke, but current stroke screening tools do not account for the evolution of neurological symptoms in this early period. We developed and validated the Paramedic Global Impression of Change (PGIC) Scale in a large, prospective, randomized trial. Methods- In the prehospital FAST-MAG (Field Administration of Stroke Therapy-Magnesium) randomized trial conducted from 2005 to 2013, EMS providers were asked to complete the PGIC Scale (5-point Likert scale values: 1-much improved, 2-mildly improved, 3-unchanged, 4-mildly worsened, 5-much worsened) for neurological symptom change during transport for consecutive patients transported by ambulance within 2 hours of onset. We analyzed PGIC concurrent validity (compared with change in Glasgow Coma Scale, Los Angeles Motor Scale), convergent validity (compared with National Institutes of Health Stroke Scale severity measure performed in the emergency department), and predictive validity (of neurological deterioration after hospital arrival and of final 90-day functional outcome). We used PGIC to characterize differential prehospital course among stroke subtypes. Results- Paramedics completed the PGIC in 1691 of 1700 subjects (99.5%), among whom 635 (37.5%) had neurological deficit evolution (32% improvement, 5.5% worsening) during a median prehospital care period of 33 (IQR, 27-39) minutes. Improvement was associated with diagnosis of cerebral ischemia rather than intracranial hemorrhage, milder stroke deficits on emergency department arrival, and more frequent nondisabled and independent 3-month outcomes. Conversely, worsening on the PGIC was associated with intracranial hemorrhage, more severe neurological deficits on emergency department arrival, more frequent treatment with thrombolytic therapy, and poor disability outcome at 3 months. Conclusions- The PGIC scale is a simple, validated measure of prehospital patient course that has the potential to provide information useful to emergency department decision-making. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT00059332.

ObjectiveTo evaluate informatics-enabled quality improvement (QI) strategies for promoting time spent on face-to-face communication between ophthalmologists and patients.MethodsThis prospective study involved deploying QI strategies during implementation of an enterprise-wide vendor electronic health record (EHR) in an outpatient academic ophthalmology department. Strategies included developing single sign-on capabilities, activating mobile- and tablet-based applications, EHR personalization training, creating novel workflows for team-based orders, and promoting problem-based charting to reduce documentation burden. Timing data were collected during 648 outpatient encounters. Outcomes included total time spent by the attending ophthalmologist on the patient, time spent on documentation, time spent on examination, and time spent talking with the patient. Metrics related to documentation efficiency, use of personalization features, use of team-based orders, and note length were also measured from the EHR efficiency portal and compared with averages for ophthalmologists nationwide using the same EHR.ResultsTime spent on exclusive face-to-face communication with patients initially decreased with EHR implementation (2.9 to 2.3 minutes, p = 0.005) but returned to the paper baseline by 6 months (2.8 minutes, p = 0.99). Observed participants outperformed national averages of ophthalmologists using the same vendor system on documentation time per appointment, number of customized note templates, number of customized order lists, utilization of team-based orders, note length, and time spent after-hours on EHR use.ConclusionInformatics-enabled QI interventions can promote patient-centeredness and face-to-face communication in high-volume outpatient ophthalmology encounters. By employing an array of interventions, time spent exclusively talking with the patient returned to levels equivalent to paper charts by 6 months after EHR implementation. This was achieved without requiring EHR redesign, use of scribes, or excessive after-hours work. Documentation efficiency can be achieved using interventions promoting personalization and team-based workflows. Given their efficacy in preserving face-to-face physician-patient interactions, these strategies may help alleviate risk of physician burnout.

BACKGROUND: Telescopic-assisted Microlaryngeal surgery (MLS), also known as video laryngoscopic surgery, is increasingly becoming popular because of the ease of the technicalities. Magnification and the improved delicacy of instrumentation help us in differentiating the extent of the lesion and performing a precise cutting out. MATERIALS AND METHODS: Forty-seven patients presented to our tertiary health center and underwent MLS by the telescopic method are taken into consideration for the present study. RESULTS: Among 47 patients who underwent surgery by telescopic method, males were predominant, and majority were in the 51–60 years of age group. A total of 19 were benign, 8 were premalignant, and 20 were malignant. Majority of the cases involved the middle third of the vocal cord and only two cases involved the posterior third of the vocal cord. All benign lesions were subjected to speech therapy, and malignant lesions were immediately sent for radiotherapy and no recurrence was noted on regular follow-up. DISCUSSION: It is easy to expose the larynx and we have never faced any difficulty in exposure of the vocal cord lesion. Delineation of the tissue in terms of morphology, site of lesion, and vascularity was very precise. Instrumentation was unimpeded, and documentation was easy. CONCLUSIONS: We conclude that the telescopic-assisted MLS is the better modality to deal with the lesions of vocal cords.

INTRODUCTION:This study aimed to assess the perception of electronic peer review of subjective, objective, assessment, plan (SOAP) notes performed by pharmacy students during their first pharmacotherapeutic course experience. METHODS:In this single-center, cross-sectional study, a questionnaire was administered to students who had undergone an electronic peer review process of a SOAP note. Four areas were assessed: baseline knowledge, development of therapeutic plans, attitudes and perceptions on peer assessment in enhancing SOAP note writing skills, and perceptions of factors that were/would have been helpful toward providing and/or receiving peer assessment. RESULTS:One hundred students completed and returned the survey (response rate 61.3%). Most students (93%) reported no prior exposure to writing SOAP notes prior to their participation. SOAP note writing was a valuable component of the module, with most students (97%) recognizing that SOAP note writing skills are important for their future practice as pharmacists. Students also acknowledged that activities in the module improved their abilities to develop (93%) and communicate (80%) patient-specific therapeutic plans in the form of SOAP notes. CONCLUSIONS:Students were comfortable receiving an assessment of a SOAP note from a classmate, and most students indicated that their classmates could provide an honest assessment of their SOAP notes. The electronic peer review process allowed students to receive feedback on their work, and this learning strategy could be further extended to the education of other functional skills that are essential in pharmacy practice.

PurposeTo assess time requirements for patient encounters and estimate after-hours demands of paper-based clinical workflows in ophthalmology.DesignTime-and-motion study with a structured survey.MethodsThis study was conducted in a single academic ophthalmology department. A convenience sample consisted of 7 attending ophthalmologists from 6 subspecialties observed during 414 patient encounters for the time-motion analysis and 12 attending ophthalmologists for the survey. Outcome measurements consisted of total time spent by attending ophthalmologists per patient and time spent on documentation, examination, and talking with patients. The survey assessed time requirements of documentation-related activities performed outside of scheduled clinic hours.ResultsAmong the 7 attending ophthalmologists observed (6 men and 1 woman), mean ± SD age 43.9 ± 7.1 years, during encounters with 414 patients (57.8 ± 24.6 years of age), total time spent per patient was 8.1 ± 4.8 minutes, with 2.8 ± 1.4 minutes (38%) for documentation, 1.2 ± 0.9 minutes (17%) for examination, and 3.3 ± 3.1 minutes (37%) for talking with patients. New patient evaluations required significantly more time than routine follow-up visits and postoperative visits. Higher clinical volumes were associated with less time per patient. Survey results indicated that paper-based documentation was associated with minimal after-hours work on weeknights and weekends.ConclusionsPaper-based documentation takes up a substantial portion of the total time spent for patient care in outpatient ophthalmology clinics but is associated with minimal after-hours work. Understanding paper-based clinical workflows may help inform targeted strategies for improving electronic health record use in ophthalmology.

Introduction: Varying intensity of advance care planning (ACP) interventions at the population level has not been compared among seriously ill patients in primary care. This project will implement, test, and disseminate real-world scalable ACP interventions among primary care clinics across three University of California Health systems. The three ACP interventions are (1) distribution of an advance directive (AD) with targeted ACP messaging, (2) the AD, messaging, plus prompting patients to engage with the Prepare For Your Care website (PREPARE), and (3) the AD, messaging, PREPARE, plus Care Coordinator engagement with patients and clinicians. Methods: We will identify a population cohort of seriously ill primary care patients and implement the ACP interventions using electronic health record (EHR) patient portals and postal mailings. Forty-five clinics across the three health systems will be cluster randomized to one of the three ACP interventions. The primary outcome for the population cohort is AD or Physician Orders for Life-Sustaining Treatment documentation in the EHR. A subset of the population cohort will be surveyed to assess patient-centered outcomes, including care consistent with goals at baseline, 12 months, and 24 months. Caregivers will be interviewed if patients are unable to be surveyed or die. ACP documentation, goal concordant care, and among decedents, health care utilization will be compared among intervention arms. Study Implementation: Challenges and Contributions: The project is guided by a Study Advisory Group and Community Advisory Groups at each site to ensure rigorous patient-centered methods and consistency of implementation. Intervention fidelity will be evaluated using the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework. Challenges to implementation of this three-site health system trial and to intervention fidelity stem from site/clinic/system cultures, increasing attention to end-of-life care from payers and regulators, and growing pressures by health systems to implement ACP interventions. Stakeholder engagement is required to ensure consistent interventions across sites.

BackgroundIn response to a changing regulatory and consumer landscape, tobacco companies developed new strategies to promote cigarettes and smoking. We examined one of these strategies: to fund and conduct scientific research related to potential benefits of nicotine, and to use their findings to promote nicotine.MethodsQualitative analysis of previously secret tobacco industry documents from the Truth (formerly Legacy) Tobacco Documents Library (industrydocuments.library.ucsf.edu/tobacco), triangulated with data from other sources, including the online search engine Google, from the 1970s to December 2017.ResultsAfter publication of the 1988 Surgeon General's report on nicotine addiction, tobacco companies (particularly RJ Reynolds) intensified efforts to promote the benefits of nicotine while downplaying its addictiveness and health risks. Activities included building relationships with academic institutions and funding scientific studies of the benefits of nicotine on cognition and other performance areas through intramural and extramural programmes. Companies then promoted their research findings through public relations campaigns, often minimising nicotine's health risks by comparing it to caffeine or coffee. These comparisons appeared in highly publicised scientific meetings and interviews with the press. Nicotine-positive messages reappeared in the popular press and on some company websites in the 2010s.ConclusionsTobacco companies implemented strategies to promote benefits of nicotine to scientific and general audiences while minimising its health risks. These strategies reappeared at the time novel tobacco products like electronic cigarettes were introduced. A greater awareness of the source of claims related to purported benefits of nicotine could inform discussions about emerging tobacco products.

PURPOSE: To create a succinct yet comprehensive evidence-based structured report template for indeterminate renal masses characterized at CT and MRI. METHODS: This IRB-exempt, iterative, multi-institutional quality improvement project was informed by published data derived from a multi-institutional survey and a multi-institutional review of CT and MRI radiology reports. A two-stage blinded Delphi process by the 16-member 12-institution Society of Abdominal Radiology Disease-Focused Panel on Renal Cell Carcinoma was conducted to create a structured report template for indeterminate renal masses evaluated at CT and MRI. Individual reporting characteristics were scored by members as core, optional, or exclude. Threshold for inclusion was ≥ 80% support. If