Saving Time for Patient Care by Optimizing Physician Note Templates: A Pilot Study

Background: At times, electronic medical records (EMRs) have proven to be less than optimal, causing longer hours behind computers, shorter time with patients, suboptimal patient safety, provider dissatisfaction, and physician burnout. These concerning healthcare issues can be positively affected by optimizing EMR usability, which in turn would lead to substantial benefits to healthcare professionals such as increased healthcare professional productivity, efficiency, quality, and accuracy. Documentation issues, such as non-standardization of physician note templates and tedious, time-consuming notes in our mother-baby unit (MBU), were discussed during meetings with stakeholders in the MBU and our hospital's EMR analysts.Objective: The objective of this study was to assess physician note optimization on saving time for patient care and improving provider satisfaction.Methods: This quality improvement pilot investigation was conducted in our MBU where four note templates were optimized: History and Physical (H and P), Progress Note (PN), Discharge Summary (DCS), and Hand-Off List (HOL). Free text elements documented elsewhere in the EMR (e.g., delivery information, maternal data, lab result, etc.) were identified and replaced with dynamic links that automatically populate the note with these data. Discrete data pick lists replaced necessary elements that were previously free texts. The new note templates were given new names for ease of accessibility. Ten randomly chosen pediatric residents completed both the old and new note templates for the same control newborn encounter during a period of one year. Time spent and number of actions taken (clicks, keystrokes, transitions, and mouse-keyboard switches) to complete these notes were recorded. Surveys were sent to MBU providers regarding overall satisfaction with the new note templates.Results: The ten residents' average time saved was 23 min per infant. Reflecting this saved time on the number of infants admitted to our MBU between January 2016 and September, 2019 which was 9373 infants; resulted in 2.6 hours saved per day, knowing that every infant averages two days length of stay. The new note templates required 69 fewer actions taken than the old ones (H and P: 11, PN: 8, DCS: 18, HOL: 32). The provider surveys were consistent with improved provider satisfaction.Conclusion: Optimizing physician notes saved time for patient care and improved physician satisfaction.

Pharmacologic therapies for the low cardiac output syndrome in children after cardiac surgery: evidence of their efficacy and trends in their use

The low cardiac output syndrome describes the phenomenon of the reduction of cardiac output that can occur following cardiac surgery requiring cardiopulmonary bypass. If unrecognized or untreated, this condition can result in significant morbidity and mortality. Along with non-pharmacologic therapies, pharmacologic agents used to help manage the low cardiac output syndrome include catecholamine inotropes, inodilators, systemic vasodilators, pulmonary vasodilators, and other classes of medications. We summarize the rationale and key evidence supporting the use of these therapies in children. In addition, utilizing provider surveys and registry reviews, we describe the current trends in the use of these medications and the variation demonstrated between providers and centers. Given the heterogeneous etiology of low cardiac output syndrome, successful management requires that pharmacologic therapies be tailored to the physiologic derangements of each patient.

Group Telehealth Interventions Fostering Social Connection Among Older Veterans and Their Families

During the early months of the COVID-19 pandemic, virtual and telephone visits rapidly replaced most in-person care within the Veterans Health Administration (VA) to reduce virus spread. To address the emerging mental health needs of older Veterans (e.g., isolation, loneliness), we developed an 8-week group treatment manual, deliverable over telephone or videoconference, to foster social connection and address pandemic anxieties. The manual was disseminated in March 2020 as a rapid response to emergent COVID-19 pandemic realities, during which many locations in the United States called for immediate self-quarantine measures for unknown durations. This talk will present the user-centered design of the manual, preliminary feasibility and acceptability findings from provider surveys, and introduce versions of the manual targeting specific populations (e.g., caregivers, Spanish speakers) currently in development or in pilot testing.

Nutrition Standards For Infants and Young Children can be Implemented by Family Child Care Home Providers

The study evaluated an educational intervention with family child care home (FCCH) providers to implement nutrition standards. A convenience sample of licensed California FCCH providers (n = 30) attended a 2-hour, in-person group training in English or Spanish on nutrition standards for infants and children aged 1 to 5 years. Provider surveys and researcher observations during meals/snacks were conducted pre- and 3 months post-intervention. Providers rated the training as excellent (average score of 4.9 on a scale of 1-5). Adherence, assessed by survey and observation and compared over time using paired t-tests, increased from an average of 36% pre-intervention to 44% post-intervention ( P = .06) of providers (n = 12) for infant standards and from 59% to 68% ( P < .001) of providers (n = 30) for child standards. One-third (39%) of providers rated infant standards and 19% of providers rated child standards as difficult to implement. Nutrition standards can be implemented by FCCH providers after an educational intervention; a larger study is warranted with a representative group of providers.

Shifts in allergy practice in a COVID-19 world: Implications of pre–COVID-19 national health care provider and patient surveys of treatments for nasal allergies

Background: Most U.S. patient and health care provider surveys with regard to nasal allergy treatments were conducted before sublingual immunotherapy (SLIT)-tablets and allergy immunotherapy (AIT) shared decision-making tools were available.Objective: Patient and health care provider surveys with regard to current perceptions of nasal allergy burden, symptoms, and treatments were conducted to compare with previous surveys and provide insight into the use of SLIT-tablets and AIT shared decision-making tools.Methods: From November-December 2019, adults (N = 510) diagnosed with nasal allergies and health care providers (N = 304) who treated nasal allergies in the United States completed surveys with regard to nasal allergy management.Results: Of the patient respondents, 42% reported that their symptoms were only somewhat controlled and 48% had avoided activities because of their nasal allergies. In all, 38% were using only over-the-counter (OTC) medications for treatment, and 42%, 7%, and 8% had ever received subcutaneous immunotherapy (SCIT), sublingual allergy drops, or SLIT-tablets, respectively; 56% and 85% reported that they had never discussed SCIT or SLIT, respectively, with their health care provider. Of the health care provider respondents, 45%, 58%, and 20% were very likely to discuss OTC medications, SCIT, or SLIT, respectively. Allergists were more inclined to discuss SCIT with their patients than other health care providers (82% versus 33%, respectively). Most allergists (67%) and other health care providers (62%) reported that they did not use an AIT shared decision-making tool, primarily because of unawareness.Conclusion: The patients with nasal allergies continued to report inadequate symptom control and activity impairment.SLIT-tablets and AIT shared decision-making tools were underused. In the coronavirus disease 2019 era, social distancing may limit office visits, which impacts SCIT administration and prompts increased use of telemedicine and a possible advantage for at-home–administered SLIT-tablets over SCIT.

Understanding Root Causes Contributing to Real-World Racial Disparities in Multiple Myeloma Care: Insights from a Mixed-Methods Study Utilizing Tethered Patient-Provider Surveys and Chart Reviews

Background Multiple myeloma (MM) is the most common hematologic malignancy among Black patients, who experience a 2-fold increase in MM risk and earlier age of onset compared with non-Black patients. Relative to other groups, Black patients are less likely to undergo autologous stem cell transplant (ASCT), receive timely access to novel therapies (e.g., immunomodulatory drugs, proteasome inhibitors), and enroll in clinical trials (Ailawadhi Blood Adv 2019). However, when Black patients with MM do undergo ASCT or receive novel therapies, their clinical outcomes match those observed in other patient groups, with some data suggesting a possible survival advantage (Fillmore Blood 2019). Therefore, in the absence of a clear biologic rationale for different treatment patterns, it is necessary to examine structural and other barriers to optimal care. In this ongoing quality improvement (QI) initiative, we are assessing and attempting to address the root causes of disparities in care delivery among patients with relapsed/refractory (R/R) MM in 2 large oncology systems. Methods Building on the design of our prior QI programs (Hussein ASCO 2020), this multicomponent initiative includes patient and provider surveys (n = 70), baseline and follow-up audits of electronic medical records (EMRs) (n = 400), and small-group, team-based audit-feedback (AF) sessions. Patient-Provider Surveys: 30 hematology/oncology healthcare providers (HCPs) and 40 patients with relapsed/refractory MM (20 African American [AA] and 20 non-AA patients, including Hispanic and non-Hispanic White patients) will complete 30-item and 35-item surveys, respectively. In addition to assessing MM treatment experiences, survey questions will evaluate health literacy, medication adherence, cancer beliefs, patient-HCP communication, and awareness of health disparities. With multiple shared questions, the surveys are designed to reveal alignments and discordances in attitudes, beliefs, perceptions, and practices regarding MM care (a) between patients and HCPs and (b) between AA and non-AA patient subgroups. In addition, HCPs' self-reported practice behaviors will be compared against documented practice patterns in the EMR audit. EMR Audits: Variables for the baseline EMR audit include patient/disease characteristics, treatment history, clinical practice metrics, and patient-centered measures (e.g., shared decision-making) documented for 100 AA and 100 non-AA adults with R/R MM and ≥2 clinic visits within the past year. Six months after the AF sessions, the follow-up EMR audit of 100 AA and 100 non-AA patients will assess changes in EMR documentation and practice behavior. Team-Based AF Sessions: HCP cohorts within each oncology system will participate in 1-hour live small-group AF sessions scheduled as part of each system's grand rounds series. Hematology/oncology teams will (a) assess system-specific practice gaps identified via the patient-provider surveys and baseline EMR audit, (b) prioritize areas for improvement, and (c) develop action plans for addressing root causes. Additional surveys completed before and after the AF sessions will measure changes in participants' beliefs and confidence in care delivery. Results Two large oncology systems in Chicago and Washington, DC, are enrolled. Preliminary HCP (n = 6) and patient (n = 9) survey data suggest discordant beliefs about patients' primary MM treatment concerns. HCPs overestimated how many patients are concerned about notfeeling confident that their treatment plan is the best for their cancer (83% vs 11%) and underestimated how many are concerned about lack of reliable transportation (0% vs 33%), difficulty communicating with their care team (0% vs 33%), meeting responsibilities at work and home (0% vs 11%), and treatment cost (0% vs 11%). Full findings from the baseline EMR audit (n = 200) and patient and HCP surveys (n = 70), as well as outcomes from the 2 small-group AF sessions (scheduled for September 2020), will be presented. Conclusions Factors contributing to racial disparities in MM care are complex. QI programs are critical tools for understanding and addressing system-specific barriers to optimal care for all patients with MM. Study Sponsor Statement The study reported in this abstract was funded by independent educational grants from AbbVie, Inc. and Celgene Corporation, who had no role in the study design, execution, analysis, or reporting. Disclosures Mikhael: Amgen, Celgene, GSK, Janssen, Karyopharm, Sanofi, Takeda: Honoraria.

Implementation of the adverse childhood experiences conversation in primary care

Background Research has focused on screening for adverse childhood experiences, rather than provision of education as a part of routine anticipatory guidance. An adverse childhood experiences ‘conversation’ is one method that has not been studied empirically but represents a complimentary or alternative approach to screening which could overcome many existing barriers. Objectives This study aims to examine parent/guardian and provider acceptability/feasibility of the adverse childhood experiences conversation during well-child visits in primary care. Methods Providers engaged in a conversation with parents/guardians of patients during well-child visits in a family medicine residency clinic. Parents/guardians and providers were surveyed following the visit to examine acceptability and feasibility. Quarterly assessments to further examine provider perspectives were completed. Data were collected for 1 year. Results In total, 238 parent/guardian and 231 provider surveys were completed. Most parents/guardians felt positively (76%) about and comfortable (81%) with the information discussed and 97% felt that the conversation should be had with their primary care provider specifically. Most providers (71%) indicated that parents/guardians were receptive to the conversation, that the conversations took 1–2 minutes (60%) and that there were few disclosures of adversity (9%), none of which required mandatory reporting. Conclusions Results suggest that the adverse childhood experiences conversation is well received by parents/guardians and providers and is feasible to implement into primary care. The conversation could be used as a complimentary or alternative method to screening to further spread knowledge of toxic stress and health, provide resources for families and promote resilience.

The Use of Online Physician Training Can Improve Patient Experience and Physician Burnout

The authors tested the efficacy of an integrated approach to improving patient experience and physician burnout using a 24-week online training program coupled with a physician engagement strategy. Physicians from different disciplines were randomized to intervention (n = 30) and control (n = 33) groups. Patient experience, physician burnout, and satisfaction data were assessed using patient and provider surveys. Comparisons were made pre and post intervention, and between the groups. Intervention group mean scores increased (+1.40 points) while control group scores dropped (−0.11 points; P = .039). Scores on physician burnout surveys for the intervention group improved in all areas and changes in 2 domains were statistically significant. In all, 73.5% of physicians felt the program was effective. This integrated intervention enhanced patient experience scores and positively affected physicians’ level of burnout, and physicians believed this exercise was useful.

Anesthesia Workspace Cleanliness and Safety: Implementation of a Novel Syringe Bracket Using 3D Printing Techniques

Purpose. Wide variability persists in the preparation and storage of common anesthetic medications despite the recognition of anesthesia workspace standardization as a national quality improvement priority. Syringe contamination and medication swaps continue to pose significant hazards to patient safety. Methods. We assessed differences in practice related to the availability of commonly prepared anesthetic medications. Using baseline provider surveys (n = 87) and anesthesia workspace audits (n = 80), we designed a custom syringe organization device using 3D printing techniques to serve as a cognitive aid and organizational tool. We iteratively tested and then deployed this device in all 60 operating rooms at a single institution, and then, repeated postintervention surveys (n = 79) and workspace audits (n = 75) one year after introduction. Results. Implementation was associated with significant improvements in provider-reported medication availability during coverage and handoff situations (43.7% versus 76.2% reporting 95% confidence preintervention versus postintervention, p<0.001). This was substantiated by audits of the anesthesia workspace which demonstrated reduced variability in the location (p<0.001) and availability (p<0.001) of key medications. Provider confidence in the cleanliness of syringes was also improved (p=0.01). A high degree of acceptance and compliance with the intervention was reported, with 80.4% of syringes observed to be stored in the device one year after implementation and approximately 95% of respondents reporting positive measures of usability and convenience. Conclusion. Use of a simple organizational device for syringes in the anesthesia workspace has numerous safety benefits. 3D printing offers improvements in adaptability and affordability compared with prior approaches.