Applied Clinical Informatics Applied Clinical Informatics aci de-de http://www.schattauer.de/rss.html Sat, 29 Apr 17 09:21:23 +0200 http://www.schattauer.de/fileadmin/assets/zeitschriften/ACI/rss_aci.jpg Development and use of a clinical decision support tool for behavioral health screening in primary... http://aci.schattauer.de/t3page/1214.html?manuscript=27456 Objective: Screening, brief intervention, and referral for treatment (SBIRT) for behavioral health (BH) is a key clinical process. SBIRT tools in electronic health records (EHR) are infrequent and rarely studied. Our goals were 1) to design and implement SBIRT using clinical decision support (CDS) in a commercial EHR; and 2) to conduct a pragmatic evaluation of the impact of the tools on clinical outcomes. Methods: A multidisciplinary team designed SBIRT workflows and CDS tools. We analyzed the outcomes using a retrospective descriptive convenience cohort with age-matched comparison group. Data extracted from the EHR were evaluated using descriptive statistics. Results: There were 2 outcomes studied: 1) development and use of new BH screening tools and workflows; and 2) the results of use of those tools by a convenience sample of 866 encounters. The EHR tools developed included a flowsheet for documenting screens for 3 domains (depression, alcohol use, and prescription misuse); and 5 alerts with clinical recommendations based on screening; and reminders for annual screening. Positive screen rate was 21% (≥1 domain) with 60% of those positive for depression. Screening was rarely positive in 2 domains (11%), and never positive in 3 domains. Positive and negative screens led to higher rates of documentation of brief intervention (BI) compared with a matched sample who did not receive screening, including changes in psychotropic medications, updated BH terms on the problem list, or referral for BH intervention. Clinical process outcomes changed even when screening was negative. Conclusions: Modified workflows for BH screening and CDS tools with clinical recommendations can be deployed in the EHR. Using SBIRT tools changed clinical process metrics even when screening was negative, perhaps due to conversations about BH not captured in the screening flowsheet. Although there are limitations to the study, results support ongoing investigation.... T. E. Burdick (1, 2, 3), R. S. Kessler (4, 5) 27456 2017-04-21 10:23:44 Application of Natural Language Processing and Network Analysis Techniques to Post-market Reports... http://aci.schattauer.de/t3page/1214.html?manuscript=27455 Objective: To evaluate the feasibility of automated dose and adverse event information retrieval in supporting the identification of safety patterns. Methods: We extracted all rabbit Anti-Thymocyte Globulin (rATG) reports submitted to the United States Food and Drug Administration Adverse Event Reporting System (FAERS) from the product’s initial licensure in April 16, 1984 through February 8, 2016. We processed the narratives using the Medication Extraction (MedEx) and the Event-based Text-mining of Health Electronic Records (ETHER) systems and retrieved the appropriate medication, clinical, and temporal information. When necessary, the extracted information was manually curated. This process resulted in a high quality dataset that was analyzed with the Pattern-based and Advanced Network Analyzer for Clinical Evaluation and Assessment (PANACEA) to explore the association of rATG dosing with post-transplant lymphoproliferative disorder (PTLD). Results: Although manual curation was necessary to improve the data quality, MedEx and ETHER supported the extraction of the appropriate information. We created a final dataset of 1,380 cases with complete information for rATG dosing and date of administration. Analysis in PANACEA found that PTLD was associated with cumulative doses of rATG >8 mg/kg, even in periods where most of the submissions to FAERS reported low doses of rATG. Conclusion: We demonstrated the feasibility of investigating a dose-related safety pattern for a particular product in FAERS using a set of automated tools.... T. Botsis (1), M. Foster (1), N. Arya (1), K. Kreimeyer (1), A. Pandey (1), D. Arya (1) 27455 2017-04-21 10:20:50 Using telephony data to facilitate discovery of clinical workflows http://aci.schattauer.de/t3page/1214.html?manuscript=27447 Background: Discovery of clinical workflows to target for redesign using methods such as Lean and Six Sigma is difficult. VoIP telephone call pattern analysis may complement direct observation and EMR-based tools in understanding clinical workflows at the enterprise level by allowing visualization of institutional telecommunications activity. Objective: To build an analytic framework mapping repetitive and high-volume telephone call patterns in a large medical center to their associated clinical units using an enterprise unified communications server log file and to support visualization of specific call patterns using graphical networks. Methods: Consecutive call detail records from the medical center’s unified communications server were parsed to cross-correlate telephone call patterns and map associated phone numbers to a cost center dictionary. Hashed data structures were built to allow construction of edge and node files representing high volume call patterns for display with an open source graph network tool. Results: Summary statistics for an analysis of exactly one week’s call detail records at a large academic medical center showed that 912,386 calls were placed with a total duration of 23,186 hours. Approximately half of all calling called number pairs had an average call duration under 60 seconds and of these the average call duration was 27 seconds. Conclusions: Cross-correlation of phone calls identified by clinical cost center can be used to generate graphical displays of clinical enterprise communications. Many calls are short. The compact data transfers within short calls may serve as automation or re-design targets. The large absolute amount of time medical center employees were engaged in VoIP telecommunications suggests that analysis of telephone call patterns may offer additional insights into core clinical workflows.... D. W. Rucker (1) 27447 2017-04-19 08:16:43 Automating Clinical Score Calculation within the Electronic Health Record http://aci.schattauer.de/t3page/1214.html?manuscript=27420 Objectives: Evidence-based clinical scores are used frequently in clinical practice, but data collection and data entry can be time consuming and hinder their use. We investigated the programmability of 168 common clinical calculators for automation within electronic health records. Methods: We manually reviewed and categorized variables from 168 clinical calculators as being extractable from structured data, unstructured data, or both. Advanced data retrieval methods from unstructured data sources were tabulated for diagnoses, non-laboratory test results, clinical history, and examination findings. Results: We identified 534 unique variables, of which 203/534 (37.8%) were extractable from structured data and 269/534 (50.4.7%) were potentially extractable using advanced techniques. Nearly half (265/534, 49.6%) of all variables were not retrievable. Only 26/168 (15.5%) of scores were completely programmable using only structured data and 43/168 (25.6%) could potentially be programmable using widely available advanced information retrieval techniques. Scores relying on clinical examination findings or clinical judgments were most often not completely programmable. Conclusion: Complete automation is not possible for most clinical scores because of the high prevalence of clinical examination findings or clinical judgments – partial automation is the most that can be achieved. The effect of fully or partially automated score calculation on clinical efficiency and clinical guideline adherence requires further study.... C. Aakre (1), M. Dziadzko (2), M. T. Keegan (2), V. Herasevich (2, 3) 27420 2017-04-12 08:22:31 Technology-Mediated Interventions and Quality of Life for Persons Living with HIV/AIDS http://aci.schattauer.de/t3page/1214.html?manuscript=27419 Background: As HIV/AIDS is considered a chronic disease; quality of life (QoL) has become an important focus for researchers and healthcare providers. Technology-mediated interventions have demonstrated improved clinical effectiveness in outcomes, such as viral suppression, for persons living with HIV/AIDS (PLWH). However, the evidence to support the impact of these interventions on QoL is lacking. Objectives: The aim of this paper was to assess the impact of technology-mediated interventions on QoL and to identify the instruments used to measure the QoL of PLWH. Methods: For this review we followed the PRISMA guidelines. A literature search was conducted in PubMed, CINAHL, Cochrane, and EMBASE databases in April 2016. Inclusion criteria limited articles to those with technology-mediated interventions as compared to usual care; articles with the population defined as HIV-infected patients; and articles with QoL measured as a health outcome in randomized controlled trials. The Cochrane Collaboration Risk of Bias Tool was used to assess study quality. Results: Of the 1,554 peer-reviewed articles returned in the searches, 10 met the inclusion criteria. This systematic review identified four types of technology-mediated interventions and two types of QoL instruments used to examine the impact of technology-mediated interventions on PLWH. Four studies of technology-mediated interventions resulted in improvement in QoL. Four studies considered QoL as a secondary outcome and resulted in a negative or neutral impact on QoL. Overall, four studies had a low risk of bias, one study had a moderate risk of bias, and the other five studies had a high risk of bias. Conclusions: The evidence to support the improvement of QoL using technology-mediated interventions is insufficient. This lack of research highlights the need for increased study of QoL as an outcome measure and the need for consistent measures to better understand the role of technology-mediated interventions in improving QoL for PLWH.... H. Cho (1), S. Iribarren (2), R. Schnall (1) 27419 2017-04-12 08:19:03 Examining Perceptions of Computerized Physician Order Entry in a Neonatal Intensive Care Unit http://aci.schattauer.de/t3page/1214.html?manuscript=27384 Background: Computerized provider order entry (CPOE) is a technology with potential to transform care delivery. While CPOE systems have been studied in adult populations, less is known about the implementation of CPOE in the neonatal intensive care unit (NICU) and perceptions of nurses and physicians using the system. Objective: To examine perceptions of clinicians before and after CPOE implementation in the NICU of a pediatric hospital. Methods: A cross-sectional survey of clinicians working in a Level III NICU was conducted. The survey was distributed before and after CPOE implementation. Participants were asked about their perception of CPOE on patient care delivery, implementation of the system, and effect on job satisfaction. A qualitative section inquired about additional concerns surrounding implementation. Responses were tabulated and analyzed using the Chi-square test. Results: The survey was distributed to 158 clinicians with a 47% response rate for pre-implementation and 45% for post-implementation. Clinicians understood why CPOE was implemented, but felt there was incomplete technical training. The expectation for increased job satisfaction and ability to recruit high-quality staff was high. However, there was concern about the ability to deliver appropriate treatments before and after implementation. Physicians were more optimistic about CPOE implementation than nurses who remained concerned that workflow may be altered. Conclusions: Introducing CPOE is a potentially risky endeavor and must be done carefully to mitigate harm. Although high expectations of the system can be met, it is important to attend to differing expectations among clinicians with varied levels of comfort with technology. Interdisciplinary collaboration is critical in planning a functioning CPOE to ensure that efficient workflow is maintained and appropriate supports for individuals with a lower degree of technical literacy is available.... K. S. Beam (1), M. Cardoso (1), M. Sweeney (2), G. Binney (3), S. N. Weingart (2) 27384 2017-04-05 08:49:51 The Building Blocks of Interoperability http://aci.schattauer.de/t3page/1214.html?manuscript=27383 Background: Patient matching is a key barrier to achieving interoperability. Patient demographic elements must be consistently collected over time and region to be valuable elements for patient matching. Objectives: We sought to determine what patient demographic attributes are collected at multiple institutions in the United States and see how their availability changes over time and across clinical sites. Methods: We compiled a list of 36 demographic elements that stakeholders previously identified as essential patient demographic attributes that should be collected for the purpose of linking patient records. We studied a convenience sample of 9 health care systems from geographically distinct sites around the country. We identified changes in the availability of individual patient demographic attributes over time and across clinical sites. Results: Several attributes were consistently available over the study period (2005–2014) including last name (99.96%), first name (99.95%), date of birth (98.82%), gender/sex (99.73%), postal code (94.71%), and full street address (94.65%). Other attributes changed significantly from 2005–2014: Social security number (SSN) availability declined from 83.3% to 50.44% (p<0.0001). Email address availability increased from 8.94% up to 54% availability (p<0.0001). Work phone number increased from 20.61% to 52.33% (p<0.0001). Conclusions: Overall, first name, last name, date of birth, gender/sex and address were widely collected across institutional sites and over time. Availability of emerging attributes such as email and phone numbers are increasing while SSN use is declining. Understanding the relative availability of patient attributes can inform strategies for optimal matching in healthcare.... A. Culbertson (1), S. Goel (2), M. B. Madden (2), N. Safaeinili (2), K. L. Jackson (2), T. Carton (3), R. Waitman (4), M. Liu (4), A. Krishnamurthy (5), L. Hall (6), N. Cappella (7), S. Visweswaran (7), M. J. Becich (7), R. Applegate (8), E. Bernstam (8), R. Rothman (9), M. Matheny (9), G. Lipori (10), J. Bian (10), W. Hogan (10), D. Bell (11), A. Martin (12), S. Grannis (12), J. Klann (13), R. Sutphen (14), A. B. O’Hara (15), A. Kho (2) 27383 2017-04-05 08:44:23 The effect of requesting a reason for non-adherence to a guideline in a long running automated... http://aci.schattauer.de/t3page/1214.html?manuscript=27368 Background: Automated reminders are employed frequently to improve guideline adherence, but limitations of automated reminders are becoming more apparent. We studied the reasons for non-adherence in the setting of automated reminders to test the hypothesis that a separate request for a reason in itself may further improve guideline adherence. Methods: In a previously implemented automated reminder system on prophylaxis for postoperative nausea and vomiting (PONV), we included additional automated reminders requesting a reason for non-adherence. We recorded these reasons in the pre-operative screening clinic, the OR and the PACU. We compared adherence to our PONV guideline in two study groups with a historical control group. Results: Guideline adherence on prescribing and administering PONV prophylaxis (dexamethasone and granisetron) all improved compared to the historical control group (89 vs. 82% (p< 0.0001), 96 vs 95% (not significant) and 90 vs 82% (p<0.0001)) while decreasing unwarranted prescription for PONV prophylaxis (10 vs. 13 %). In the pre-operative screening clinic, the main reason for not prescribing PONV prophylaxis was disagreement with the risk estimate by the decision support system. In the OR/PACU, the main reasons for not administering PONV prophylaxis were: ‘unintended non-adherence’ and ‘failure to document’. Conclusions: In this study requesting a reason for non-adherence is associated with improved guideline adherence. The effect seems to depend on the underlying reason for non-adherence. It also illustrates the importance of human factors principles in the design of decision support. Some reasons for non-adherence may not be influenced by automated reminders.... F. O. Kooij (1), T. Klok (2), B. Preckel (1), M. W. Hollmann (1), J. E. Kal (2) 27368 2017-03-29 08:26:38 Implementation of a single sign-on system between practice, research and learning systems http://aci.schattauer.de/t3page/1214.html?manuscript=27367 Background: Multiple specialized electronic medical systems are utilized in the health enterprise. Each of these systems has their own user management, authentication and authorization process, which makes it a complex web for navigation and use without a coherent process workflow. Users often have to remember multiple passwords, login/logout between systems that disrupt their clinical workflow. Challenges exist in managing permissions for various cadres of health care providers. Objectives: This case report describes our experience of implementing a single sign-on system, used between an electronic medical records system and a learning management system at a large academic institution with an informatics department responsible for student education and a medical school affiliated with a hospital system caring for patients and conducting research. Methods: At our institution, we use OpenMRS for research registry tracking of interventional radiology patients as well as to provide access to medical records to students studying health informatics. To provide authentication across different users of the system with different permissions, we developed a Central Authentication Service (CAS) module for OpenMRS, released under the Mozilla Public License and deployed it for single sign-on across the academic enterprise. The module has been in implementation since August 2015 to present, and we assessed usability of the registry and education system before and after implementation of the CAS module. 54 students and 3 researchers were interviewed. Results: The module authenticates users with appropriate privileges in the medical records system, providing secure access with minimal disruption to their workflow. No passwords requests were sent and users reported ease of use, with streamlined workflow. Conclusions: The project demonstrates that enterprise-wide single sign-on systems should be used in healthcare to reduce complexity like “password hell”, improve usability and user navigation. We plan to extend this to work with other systems used in the health care enterprise.... S. Purkayastha (1), J. W. Gichoya (2), S. A. Addepally (1) 27367 2017-03-29 08:24:24 Open Access: Harnessing scientific literature reports for pharmacovigilance http://aci.schattauer.de/t3page/1214.html?manuscript=27338 Objectives: We seek to develop a prototype software analytical tool to augment FDA regulatory reviewers’ capacity to harness scientific literature reports in PubMed/MEDLINE for pharmacovigilance and adverse drug event (ADE) safety signal detection. We also aim to gather feedback through usability testing to assess design, performance, and user satisfaction with the tool. Methods: A prototype, open source, web-based, software analytical tool generated statistical disproportionality data mining signal scores and dynamic visual analytics for ADE safety signal detection and management. We leveraged Medical Subject Heading (MeSH) indexing terms assigned to published citations in PubMed/MEDLINE to generate candidate drug-adverse event pairs for quantitative data mining. Six FDA regulatory reviewers participated in usability testing by employing the tool as part of their ongoing real-life pharmacovigilance activities to provide subjective feedback on its practical impact, added value, and fitness for use. Results: All usability test participants cited the tool’s ease of learning, ease of use, and generation of quantitative ADE safety signals, some of which corresponded to known established adverse drug reactions. Potential concerns included the comparability of the tool’s automated literature search relative to a manual ‘all fields’ PubMed search, missing drugs and adverse event terms, interpretation of signal scores, and integration with existing computer-based analytical tools. Conclusions: Usability testing demonstrated that this novel tool can automate the detection of ADE safety signals from published literature reports. Various mitigation strategies are described to foster improvements in design, productivity, and end user satisfaction.... A. Sorbello (1), A. Ripple (2), J. Tonning (1), M. Munoz (3), R. Hasan (1), T. Ly (1), H. Francis (1), O. Bodenreider (2) 27338 2017-03-22 09:01:21 Application of Electronic Algorithms to Improve Diagnostic Evaluation for Bladder Cancer http://aci.schattauer.de/t3page/1214.html?manuscript=27337 Background: Strategies to ensure timely diagnostic evaluation of hematuria are needed to reduce delays in bladder cancer diagnosis. Objective: To evaluate the performance of electronic trigger algorithms to detect delays in hematuria follow-up. Methods: We developed a computerized trigger to detect delayed follow-up action on a urinalysis result with high-grade hematuria (>50 red blood cells/high powered field). The trigger scanned clinical data within a Department of Veterans Affairs (VA) national data repository to identify all patient records with hematuria, then excluded those where follow-up was unnecessary (e.g., terminal illness) or where typical follow-up action was detected (e.g., cystoscopy). We manually reviewed a randomly-selected sample of flagged records to confirm delays. We performed a similar analysis of records with hematuria that were marked as not delayed (non-triggered). We used review findings to calculate trigger performance. Results: Of 310,331 patients seen between 1/1/2012–12/31/2014, the trigger identified 5,857 patients who experienced high-grade hematuria, of which 495 experienced a delay. On manual review of 400 randomly-selected triggered records and 100 non-triggered records, the trigger achieved positive and negative predictive values of 58% and 97%, respectively. Conclusions: Triggers offer a promising method to detect delays in care of patients with high-grade hematuria and warrant further evaluation in clinical practice as a means to reduce delays in bladder cancer diagnosis.... D. R. Murphy (1, 2), A. N. D. Meyer (1, 2), V. Vaghani (1, 2), E. Russo (1, 2), D. F. Sittig (3), K. A. Richards (4), L. Wei (1, 2), L. Wu (1), H. Singh (1, 2) 27337 2017-03-22 08:58:45 Healthcare Team Perceptions of a Portal for Parents of Hospitalized Children Before and After... http://aci.schattauer.de/t3page/1214.html?manuscript=27326 Background: Patient electronic health record (EHR) portals can enhance patient and family engagement by providing information and a way to communicate with their healthcare team (HCT). However, portal implementation has been limited to ambulatory settings and met with resistance from HCTs. Objective: We evaluated HCT perceptions before and 6-months after implementation of an inpatient EHR portal application on a tablet computer given to parents of hospitalized children. Methods: This repeated cross-sectional study was conducted with HCT members (nurses, physicians, ancillary staff) on a medical/surgical unit at a quaternary children’s hospital. From December 2014-June 2015, parents of children <12 years old were given a portal application on a tablet computer. It provided real-time vitals, medications, lab results, schedules, education, HCT information and a way to send the HCT messages/requests. HCT members completed surveys pre- and post-implementation regarding their portal perceptions. Pre-post differences in HCT perceptions were compared using chi-squared, Mann-Whitney and Kruskall Wallis tests. Results: Pre-implementation, HCT respondents (N=94) were generally optimistic about the benefits of a portal for parents; however, all anticipated challenges to portal use. Over the next 6-months, 296 parents used the portal, sending 176 requests and 36 messages. Post-implementation, HCT respondent (N=70) perceptions of these challenges were significantly reduced (all p<0.001), including: parents (will) have too many questions (69 vs. 3%, pre-post), parents (will) know results before the HCT (65 vs. 1%), staff (would be/are) skeptical (43 vs. 21%) and there (will be/is) not enough technical support (28 vs. 1%). Conclusions: All HCT respondents anticipated challenges in providing a portal to parents of hospitalized children; however, these concerns were minimized after implementation.... M. M. Kelly (1, 2), S. M. Dean (1), P. Carayon (2, 3), T. B. Wetterneck (2, 3, 4), P. L. T. Hoonakker (2) 27326 2017-03-15 07:52:08 Meaningful Use of an Electronic Personal Health Record (ePHR) among Pediatric Cancer Survivors http://aci.schattauer.de/t3page/1214.html?manuscript=27325 Background and Objectivs: Survivors of pediatric and adolescent cancer are at an increased risk of chronic and debilitating health conditions and require life-long specialized care. Stand-alone electronic personal health records (ePHRs) may aid their self-management. This analysis characterizes young adult survivors and parents who meaningfully use an ePHR, Cancer SurvivorLinkTM, designed for survivors of pediatric and adolescent cancer. Methods: This was a retrospective observational study of patients seen at a pediatric survivor clinic for annual survivor care. Young adult survivors and/or parent proxies for survivors <18 years old who completed ePHR registration prior to their appointment or within 90 days were classified as registrants. Registrants who uploaded or downloaded a document and/or shared their record were classified as meaningful users. Results: Overall, 23.7% (148/624) of survivors/parents registered and 38% of registrants used SurvivorLink meaningfully. Young adult registrants who transferred to adult care during the study period were more likely to be meaningful users (aOR: 2.6 (95% CI: 1.1, 6.1)) and used the ePHR twice as frequently as those who continued to receive care in our institution’s pediatric survivor clinic. Among survivors who continued to receive care at our institution, being a registrant was associated with having an annual follow-up visit (aOR: 2.6 (95% CI: 1.2, 5.8)). Conclusions: While ePHRs may not be utilized by all survivors, SurvivorLink is a resource for a subset and may serve as an important bridge for patients who transfer their care. Using SurvivorLink was also associated with receiving recommended annual survivor care.... R. S. Williamson (1), B. O. Cherven (1), J. Gilleland Marchak (1, 2), P. Edwards (3), M. Palgon (3), C. Escoffery (4), L. R. Meacham (1, 2), A. C. Mertens (1, 2) 27325 2017-03-15 07:49:00 Medication Use among Veterans across Health Care Systems http://aci.schattauer.de/t3page/1214.html?manuscript=27295 Introduction: Dual healthcare system use can create gaps and fragments of information for patient care. The Department of Veteran Affairs is implementing a health information exchange (HIE) program called the Virtual Lifetime Electronic Record (VLER), which allows providers to access and share information across healthcare systems. HIE has the potential to improve the safety of medication use. However, data regarding the pattern of outpatient medication use across systems of care is largely unknown. Therefore, the objective of this study is to describe the prevalence of medication dispensing across VA and non-VA health care systems among a cohort Veteran population. Methods: This study included all Veterans who had two outpatient visits or one inpatient visit at the Indianapolis VA during a 1-year period prior to VLER enrollment. Source of medication data was assessed at the subject level, and categorized as VA, INPC (non-VA), or both. The primary target was identification of sources for medication data. Then, we compared the mean number of prescriptions, as well as overall and pairwise differences in medication dispensing. Results: Out of 52,444 Veterans, 17.4% of subjects had medication data available in a regional HIE. On average, 40 prescriptions per year were prescribed for Veterans who used both sources compared to 29 prescriptions per year from VA only and 25 prescriptions per year from INPC only sources. The annualized prescription rate of Veterans in the dual use group was 36% higher than those who had only VA data available and 61% higher than those who had only INPC data available. Conclusions: Our data demonstrated that 17.4% of subjects had medication use identified from non-VA sources, including prescriptions for antibiotics, antineoplastics, and anticoagulants. These data support the need for HIE programs to improve coordination of information, with the potential to reduce adverse medication interactions and improve medication safety.... K. A Nguyen (1, 2), D. A. Haggstrom (1, 3, 4), S. Ofner (5), S. M. Perkins (5), D. D. French (6), L. J. Myers (1), M. Rosenman (7), M. Weiner (1, 4, 8), B. E. Dixon (1, 3, 4), A. J. Zillich (1, 2) 27295 2017-03-08 08:02:36 Code Status Reconciliation to Improve Identification and Documentation of Code Status in Electronic... http://aci.schattauer.de/t3page/1214.html?manuscript=27294 Background: Code status (CS) of a patient (part of their end-of-life wishes) can be critical information in healthcare delivery, which can change over time, especially at transitions of care. Although electronic health record (EHR) tools exist for medication reconciliation across transitions of care, much less attention is given to CS, and standard EHR tools have not been implemented for CS reconciliation (CSR). Lack of CSR creates significant potential patient safety and quality of life issues. Objective: To study the tools, workflow, and impact of clinical decision support (CDS) for CSR. Methods: We established rules for CS implementation in our EHR. At admission, a CS is required as part of a patient’s admission order set. Using standard CDS tools in our EHR, we built an interruptive alert for CSR at discharge if a patient did not have the same inpatient (current) CS at discharge as that prior to admission CS. Results: Of 80,587 admissions over a four year period (2 years prior to and post CSR implementation), CS discordance was seen in 3.5% of encounters which had full code status prior to admission, but Do Not Resuscitate (DNR) CS at discharge. In addition, 1.4% of the encounters had a different variant of the DNR CS at discharge when compared with CS prior to admission. On pre-post CSR implementation analysis, DNR CS per 1000 admissions per month increased significantly among patients discharged and in patients being admitted (mean ± SD: 85.36 ± 13.69 to 399.85 ± 182.86, p<0.001; and 1.99 ± 1.37 vs 16.70 ± 4.51, p<0.001, respectively). Conclusion: EHR enabled CSR is effective and represents a significant informatics opportunity to help honor patients’ end-of-life wishes. CSR represents one example of non-medication reconciliation at transitions of care that should be considered in all EHRs to improve care quality and patient safety.... V. G. Jain (1, 2), P. J. Greco (3, 4, 5), D. C. Kaelber (1, 3, 4, 5) 27294 2017-03-08 07:59:57 Satisfaction and Improvements in Peritoneal Dialysis Outcomes Associated with Telehealth http://aci.schattauer.de/t3page/1214.html?manuscript=27267 Background and Significance: End stage renal disease (ESRD) affects approximately 660,000 persons in the US each year, representing a significant financial burden to the health care system and affected individuals. Telehealth approaches to care offer an important means of reducing costs as well as increasing autonomy for patients. Understanding patient satisfaction with telehealth provides a key towards eventual scalability. Materials and Methods: Quarterly surveys were conducted to characterize satisfaction with remote biometric monitoring (RBM) for blood pressure, weight, glucose and peritoneal dialysis (PD)-specific educational online videos for ESRD patients using PD. Results: Of 300 participants, 67% participated in the surveys and provided baseline and at least one follow-up assessment. The majority were 45 to 64 years of age (50.5%), Black (64.5%), married or living with significant other (52.0%), and had more than a high school degree (73.0%). RBM was associated with perceived autonomy and confidence in health care activities and decreased negative perceptions of PD care and ESRD. The majority of participants (80.1%) indicated that they were satisfied or completely satisfied with the system. Participants found that the interface increased confidence, reduced frustration, and related perceptions were significantly and positively altered (p<0.05) for each of the separate telehealth components. Educational videos were well utilized with nearly half of the participants (42.5%) reporting that they watched at least one of the videos, and the majority reporting that the videos seen had an overall positive impact on health. Discussion and Conclusions: Supplementing PD with telehealth has the potential to have a positive impact on patient perceptions of PD care and consequently improve clinical outcomes.... M. Magnus (1), N. Sikka (2), T. Cherian (3), S. Q. Lew (4) 27267 2017-03-01 08:04:20 Electronic Alerts Improve Immunization Rates in Two-month-old Premature Infants Hospitalized in the... http://aci.schattauer.de/t3page/1214.html?manuscript=27266 Objective: To determine if an electronic alert improves 2 month immunization rates in infants remaining hospitalized in the neonatal intensive care unit. Methods: Institutional Review Board-approved retrospective chart review of 261 infants with birth weights <2 kg and still hospitalized at ≥ 58 days. Charts were reviewed between 2009 and 2013, before and after the 2011 electronic alert was instituted in the electronic medical record from days 56 to 67 to remind providers that immunizations were due. Order and administration dates of two-month vaccine components (Diphtheria, Haemophilus influenza B, Hepatitis B, Pertussis, Pneumococcal, Polio, Tetanus) were determined, and infants were considered fully immunized, partially immunized, or unimmunized by day 90 or discharge, whichever came first. Results: After the alert, the timing of vaccine orders decreased from day 67 to day 61 (p<0.0001) and vaccine administration decreased from day 71 to day 64 (p<0.0001). Missing vaccine orders decreased from 14% [17/121] to 3% [4/140] (p=0.001) with missing administrations decreasing from 21% [26/121] to 4% [6/140] (p<0.0001). Fully immunized rates increased from 71% [86/121] to 94% [132/140] (p<0.0001). Conclusions: A significant improvement in immunization rates in two-month-old infants in the neonatal intensive care unit occurred by 90 days after implementing an alert in the electronic medical record.... K. D. Ernst (1) 27266 2017-03-01 08:00:25 Getting what they need when they need it http://aci.schattauer.de/t3page/1214.html?manuscript=27209 Background: Consumer health informatics (CHI) such as web-based applications may provide the platform for enabling the over 15 million family caregivers of patients with Alzheimer’s Disease or related dementias the information they need when they need it to support behavioral symptom management. However, for CHI to be successful, it is necessary that it be designed to meet the specific information needs of family caregivers in the context in which caregiving occurs. A sociotechnical systems approach to CHI design can help to understand the contextual complexities of family caregiving and account for those complexities in the design of CHI for family caregivers. Objectives: This study used a sociotechnical systems approach to identify barriers to meeting caregivers’ information needs related to the management of dementia-related behavioral symptoms, and to derive design implications that overcome barriers for caregiver-focused web-based platforms. We have subsequently used these design implications to inform the development of a web-based platform, WeCareAdvisor,TM which provides caregivers with information and an algorithm by which to identify and manage behavioral symptoms for which they seek management strategies. Methods: We conducted 4 focus groups with family caregivers (N=26) in a Midwestern state. Qualitative content analysis of the data was guided by a sociotechnical systems framework. Results: We identified nine categories of barriers that family caregivers confront in obtaining needed information about behavioral symptom management from which we extrapolated design implications for a web-based platform. Based on interactions within the sociotechnical system, three critical information needs were identified: 1) timely access to information, 2) access to information that is tailored or specific to caregiver’s needs and contexts, and 3) usable information that can directly inform how caregivers’ manage behaviors. Conclusions: The sociotechnical system framework is a useful approach for identifying information needs of family caregivers to inform design of web-based platforms that are user-centered.... N. E. Werner (1, 2, 3), B. Stanislawski (4), K. A. Marx (5, 6), D. C. Watkins (4), M. Kobayashi (5, 6), H. Kales (4), L. N. Gitlin (4, 5, 7) 27209 2017-02-22 07:46:10 Accelerating the Benefits of the Problem Oriented Medical Record http://aci.schattauer.de/t3page/1214.html?manuscript=27180 J. Buchanan (1) 27180 2017-02-15 07:56:44 Evaluating a Modular Decision Support Application For Colorectal Cancer Screening http://aci.schattauer.de/t3page/1214.html?manuscript=27179 Background: There is a need for health information technology evaluation that goes beyond randomized controlled trials to include consideration of usability, cognition, feedback from representative users, and impact on efficiency, data quality, and clinical workflow. This article presents an evaluation illustrating one approach to this need using the Decision-Centered Design framework. Objective: To evaluate, through a Decision-Centered Design framework, the ability of the Screening and Surveillance App to support primary care clinicians in tracking and managing colorectal cancer testing. Methods: We leveraged two evaluation formats, online and in-person, to obtain feedback from a range primary care clinicians and obtain comparative data. Both the online and in-person evaluations used mock patient data to simulate challenging patient scenarios. Primary care clinicians responded to a series of colorectal cancer-related questions about each patient and made recommendations for screening. We collected data on performance, perceived workload, and usability. Key elements of Decision-Centered Design include evaluation in the context of realistic, challenging scenarios and measures designed to explore impact on cognitive performance. Results: Comparison of means revealed increases in accuracy, efficiency, and usability and decreases in perceived mental effort and workload when using the Screening and Surveillance App. Conclusion: The results speak to the benefits of using the Decision-Centered Design approach in the analysis, design, and evaluation of Health Information Technology. Furthermore, the Screening and Surveillance App shows promise for filling decision support gaps in current electronic health records.... L. G. Militello (1), J. B. Diiulio (1), M. R. Borders (1), C. E. Sushereba (1), J. J. Saleem (2), D. Haverkamp (3), T. F. Imperiale (4, 5, 6) 27179 2017-02-15 07:52:33 Open Access: Measuring Practicing Clinicians’ Information Literacy http://aci.schattauer.de/t3page/1214.html?manuscript=27178 Background: As healthcare moves towards technology-driven population health management, clinicians must adopt complex digital platforms to access health information and document care. Objectives: This study explored information literacy, a set of skills required to effectively navigate population health information systems, among primary care providers in one Veterans’ Affairs (VA) medical center. Methods: Information literacy was assessed during an 8-month randomized trial that tested a population health (panel) management intervention. Providers were asked about their use and comfort with two VA digital tools for panel management at baseline, 16 weeks, and post-intervention. An 8-item scale (range 0–40) was used to measure information literacy (Cronbach’s α=0.84). Scores between study arms and provider types were compared using paired t-tests and ANOVAs. Associations between self-reported digital tool use and information literacy were measured via Pearson’s correlations. Results: Providers showed moderate levels of information literacy (M= 27.4, SD 6.5). There were no significant differences in mean information literacy between physicians (M=26.4, SD 6.7) and nurses (M=30.5, SD 5.2, p=0.57 for difference), or between intervention (M=28.4, SD 6.5) and control groups (M=25.1, SD 6.2, p=0.12 for difference). Information literacy was correlated with higher rates of self-reported information system usage (r=0.547, p=0.001). Clinicians identified data access, accuracy, and interpretability as potential information literacy barriers. Conclusions: While exploratory in nature, cautioning generalizability, the study suggests that measuring and improving clinicians’ information literacy may play a significant role in the implementation and use of digital information tools, as these tools are rapidly being deployed to enhance communication among care teams, improve health care outcomes, and reduce overall costs.... B. E. Dixon (1, 2, 3), K. Barboza (4), A. E. Jensen (4, 5), K. J. Bennett (4, 5), S. E. Sherman (5, 4), M. D. Schwartz (4, 5) 27178 2017-02-15 07:48:27 Screening Consolidated Clinical Document Architecture (CCDA) Documents for Sensitive Data Using a... http://aci.schattauer.de/t3page/1214.html?manuscript=27137 Background: The Centers for Medicare & Medicaid Services’ Stage 2 final rule requires that eligible hospitals provide a visit summary electronically at transitions of care in order to qualify for “meaningful use” incentive payments. However, Massachusetts state law and Federal law prohibit the transmission of documents containing “sensitive” data unless there is a new patient consent for each transmission. Objectives: To describe the implementation and evaluation of a rule-based decision support system used to screen transition of care documents for sensitive data. Methods: We implemented a rule-based document screening system to identify transition of care documents that might contain sensitive data. The transmission of detected documents is withheld until a new patient consent is obtained. The documents that were flagged as containing sensitive data were reviewed in two different time periods to verify that the decision support system was not missing documents or withholding more documents than necessary. Results: The rule-based screening system has been in regular production use for the past 18 months. During the first evaluation period, 3% of 5,841 documents were identified as containing sensitive data (true-positive rate of 44%). After additional enhancements to the rules, the system was evaluated a second time and 4.5% of 6,935 documents were identified as containing sensitive data (true-positive rate of 98.4%). Conclusion: The analysis of the system demonstrates that production rules can be used to automatically screen the content of transition of care documents for sensitive data. The utilization of the rule-based decision support system enabled our hospitals to achieve meaningful use and, at the same time, remain compliant with state and federal laws.... B. H. Rocha (1, 2), D. Pabbathi (3), M. Schaeffer (3), H. S. Goldberg (2, 3, 4) 27137 2017-02-08 09:03:51 Open Access: Effect of a Novel Clinical Decision Support Tool on the Efficiency and Accuracy of... http://aci.schattauer.de/t3page/1214.html?manuscript=27136 Background: The 2013 American College of Cardiology / American Heart Association Guidelines for the Treatment of Blood Cholesterol emphasize treatment based on cardiovascular risk. But finding time in a primary care visit to manually calculate cardiovascular risk and prescribe treatment based on risk is challenging. We developed an informatics-based clinical decision support tool, MayoExpertAdvisor, to deliver automated cardiovascular risk scores and guideline-based treatment recommendations based on patient-specific data in the electronic heath record. Objective: To assess the impact of our clinical decision support tool on the efficiency and accuracy of clinician calculation of cardiovascular risk and its effect on the delivery of guideline-consistent treatment recommendations. Methods: Clinicians were asked to review the EHR records of selected patients. We evaluated the amount of time and the number of clicks and keystrokes needed to calculate cardiovascular risk and provide a treatment recommendation with and without our clinical decision support tool. We also compared the treatment recommendation arrived at by clinicians with and without the use of our tool to those recommended by the guidelines. Results: Clinicians saved 3 minutes and 38 seconds in completing both tasks with MayoExpertAdvisor, used 94 fewer clicks and 23 fewer key strokes, and improved accuracy from the baseline of 60.61% to 100% for both the risk score calculation and guideline-consistent treatment recommendation. Conclusion: Informatics solution can greatly improve the efficiency and accuracy of individualized treatment recommendations and have the potential to increase guideline compliance.... M. R. Scheitel (1), M. E. Kessler (2), J. L. Shellum (1), S. G. Peters (3), D. S. Milliner (4), H. Liu (5), R. Komandur Elayavilli (5), K. A. Poterack (6), T. A. Miksch (6), J. Boysen (1), R. A. Hankey (7), R. Chaudhry (1, 2) 27136 2017-02-08 08:58:17 Erratum to: Preprocessing structured clinical data for predictive modeling and decision support http://aci.schattauer.de/t3page/1214.html?manuscript=27115 27115 2017-02-01 07:42:07 Leveraging the Value of Human Relationships to Improve Health Outcomes http://aci.schattauer.de/t3page/1214.html?manuscript=27114 Objectives: Despite significant awareness on the value of leveraging patient relationships across the healthcare continuum, there is no research on the potential of using Electronic Health Record (EHR) systems to store structured patient relationship data, or its impact on enabling better healthcare. We sought to identify which EHR systems supported effective patient relationship data collection, and for systems that do, what types of relationship data is collected, how this data is used, and the perceived value of doing so. Materials and methods: We performed a literature search to identify EHR systems that supported patient relationship data collection. Based on our results, we defined attributes of an effective patient relationship model. The Open Medical Record System (OpenMRS), an open source medical record platform for underserved settings met our eligibility criteria for effective patient relationship collection. We performed a survey to understand how the OpenMRS patient relationship model was used, and how it brought value to implementers. Results: The OpenMRS patient relationship model has won widespread adoption across many implementations and is perceived to be valuable in enabling better health care delivery. Patient relationship information is widely used for community health programs and enabling chronic care. Additionally, many OpenMRS implementers were using this feature to collect custom relationship types for implementation specific needs. Conclusions: We believe that flexible patient relationship data collection is critical for better healthcare, and can inform community care and chronic care initiatives across the world. Additionally, patient relationship data could also be leveraged for many other initiatives such as patient centric care and in the field of precision medicine.... S. N. Kasthurirathne (1), B. W. Mamlin (2, 3), T. Cullen (2, 3) 27114 2017-02-01 07:36:18