While electronic health record (EHR)-based tools for refugee health screening exist, support for other immigrant children has lagged. Reasons include lack of time, difficulty determining screening eligibility, and lack of awareness of screening recommendations. EHR-based tools to promote immigrant child health screening (ICHS) can address these challenges, but guidance is needed for tools that are usable by clinicians and acceptable to immigrant families.Develop useful EHR-based tools to support ICHS while incorporating evaluation of acceptability, usability, and implementation effort.We followed a five-step human-centered design approach to develop EHR-based tools for ICHS. This included: (1) representative users completing semi-structured interviews. (2) Health professionals and community advisory groups providing ongoing guidance. (3) Developing a functional prototype. (4) Usability testing of the prototype. And (5) an assessment of the implementation effort involving a second site installation coupled with expert implementation time estimations.Sixteen interviewees discussed screening barriers and how EHR-based tools could support discussing nativity (country of birth). From the interview findings and in consultation with advisory group members, we developed an EHR-based toolkit including noninterruptive alerts, an order set, and a documentation prompt. Ten clinicians completed usability testing. All recognized the alert and asked country of birth. Most (9) were satisfied with the system. All felt it was easy to use, helpful, and would not hinder patient care. Content experts (n = 8) estimated installation times (range: 4-20 hours, median 10) with high levels of confidence (range: 1-5, median 4). A second-site test installation required 7.25 hours.Our EHR-based tools designed with the guidance of experts were highly rated on usability and can help clinicians identify patients eligible for ICHS in a sensitive manner. Installation testing demonstrated that this content could be implemented in a reasonable timeframe at external sites.

BackgroundTerminologies, such as Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) and Solor, assist with knowledge representation and management, data integration, and triggering clinical decision support (CDS) rules. Semantic relations in these terminologies provide explicit meaning in compositional expressions, which assist with many of the above-listed activities.ObjectiveThe aims of this research are to: (1) identify semantic relations that are not fully present in SNOMED CT and Solor and (2) use these identified semantic relations with terms that are currently present in SNOMED CT and Solor to form triples.MethodsWe identified relations that were not fully present in either SNOMED CT or Solor and were important for VA Knowledge Artifacts (KNARTS). These terms and the relations were formed into triples. The relations, terms, classifications, and sentences were used to implement the relations in the High Definition-Natural Language Processing (HD-NLP) program.ResultsThere are a total of 38 semantic relations. These had use cases built for each and were implemented in the Solor HD-NLP server for tagging of KNARTS.ConclusionsThese new SNOMED CT and Solor semantic relations will give clinicians the ability to add more detail and meaning to their clinical notes. This can improve our ability to trigger CDS rules, leading to improved CDS provided to clinicians during patient care.

ObjectiveThis study aimed to examine user actions within a clinical decision support (CDS) alert addressing hypertension (HTN) in chronic kidney disease (CKD).MethodsA pragmatic randomized controlled trial of a CDS alert for primary care patients with CKD and uncontrolled blood pressure included prechecked default orders for medication initiation or titration, basic metabolic panel (BMP), and nephrology electronic consult (e-consult). We examined each type of action and calculated percentages of placed and signed orders for subgroups of firings.ResultsThere were firings for medication initiation (813) and medication titration (430), and every firing also included orders for nephrology e-consult (1,243) and BMP (1,243). High rates of override (59.6%) and deferral (14.6%) were observed, and CDS-recommended orders were only signed about one-third of the time from within the alert. The percentage of orders that were signed after being placed within the alert was higher for medication initiation than for medication titration (33 vs. 12.0% for angiotensin-converting enzyme inhibitors [ACEi] and 38.8 vs. 14% for angiotensin II receptor blockers [ARBs]). Findings suggest that users are hesitant to commit to immediate action within the alert.ConclusionEvaluating user interaction within alerts reveals nuances in physician preferences and workflow that should inform CDS alert design. This study is registered with the Clinicaltrials.gov Trial Registration (identifier: NCT03679247).

Pediatric cancer patients with fever and neutropenia are at risk for bacterial sepsis, traditionally requiring extended hospital stays on antibiotics until neutrophil counts recover. According to a newly validated scoring system, a subset of these patients is at lower risk and eligible for early discharge and reduced intravenous (IV) antibiotic exposure.Reduce length-of-stay (LOS) for febrile neutropenic patients using clinical decision support (CDS) to identify low-risk patients.A CDS system was developed to (1) screen febrile neutropenic patients using a validated clinical decision rule, (2) surface when low-risk patients become eligible for discharge, and (3) facilitate close phone follow-up for patients discharged early. The system was implemented in March 2023 and iteratively refined based on usability testing.Postimplementation, LOS did not improve significantly, and uptake of the CDS tool remained low. Though the tool had the potential to reduce LOS, the limited staff engagement was a significant barrier to success. Safety outcomes, including ICU readmissions and mortality, remained unaffected.Despite carefully designed CDS applying an evidence-based scoring system and using human-centered design methodology, the failure to achieve the desired reduction in LOS was primarily due to insufficient uptake by clinical staff. This highlights the need for stronger strategies to ensure clinician engagement and integration into workflows for CDS tools to be effective.

Effective postoperative care is crucial for the success of total joint arthroplasty (TJA) and prevention of unnecessary emergency department (ED) visits. We explore the feasibility and acceptability of utilizing an Interactive Voice Response System (IVRS) to enhance postoperative monitoring in primary TJA patients.This pilot study was conducted with 24 participants undergoing primary TJA randomly assigned to an intervention group receiving IVRS calls (n = 12) or a control group (n = 12) receiving standard postoperative follow-up. Feasibility and acceptability were assessed through patient satisfaction and willingness to participate. Outcome measures included the Short Form 36 Health Survey Questionnaire, the Hip Disability and Osteoarthritis Outcome Score (HOOS), the Knee Injury and Osteoarthritis Outcome Score (KOOS), and pain assessments using the Visual Analog Scale.The IVRS group exhibited a 92.3% retention rate, with 100% completion of the 12-week study. IVRS calls triggered 10 notifications, addressing pain control and respiratory concerns, leading to timely interventions and preventing ED visits. The IVRS demonstrated an 81% (95% confidence interval, 77.1-86.0%) overall response rate, with high patient satisfaction (92% finding calls "very useful").This pilot study demonstrates the feasibility and acceptability of an IVRS-based postoperative follow-up system for TJA patients. Patients reported high satisfaction and expressed willingness to use the IVRS service again.

Background The NIH Pragmatic Trials Collaboratory supports the design and conduct of 31 embedded pragmatic clinical trials, and many of these trials use patient-reported outcome measures (PROMs) to provide valuable information about the patients' health and wellness. Often these trials enroll medically underserved patients, including people with incomes below the federal poverty threshold, racial or ethnic minority groups, or rural or frontier communities.Objectives In this series of trial case reports, we provide lessons learned about collecting PROMs in these populations. Unbiased collection of PROM data is critical to increase the generalizability of trial outcomes and to address health inequities. Use of electronic health records (EHRs) and other digital modes of PROM administration has gained traction. However, engagement with these modes is often low among populations prone to disparity due to lower digital proficiency, device access, and uptake of EHR portals and web interfaces.Methods To maximize the completeness and representativeness of their trial outcome data, study teams tested a range of strategies to improve PROM response rates with emphasis on disparities prone and underserved patient groups. This manuscript describes the approaches, their implementation, and the targeted populations.Conclusion Optimized PROM collection required hybrid approaches with multiple outreach modes, high-touch methods, creativity in promoting digital uptake, multimodal participant engagement, and text messaging.

With an aging population preferring to age in place, there's a need for efficient health monitoring systems in eldercare. This study assesses the effectiveness of a linguistic summary alert system compared with a standard health alert system requiring data visualization interpretation by clinicians. A total of 110 older adults from seven facilities were monitored for health alerts throughout 2019. The study analyzed the frequency of email alert interactions and surveyed clinicians' perceptions before and after system-specific training. Linguistic alerts demonstrated a significant reduction in the need for data interface consultation, as indicated by a lower click-through rate for email alerts. Clinicians expressed a strong preference for linguistic alerts, which streamlined their decision-making process. Despite this, the post-training survey interval and limited participant demographic constrained the findings' generalizability. The linguistic summary alert system was found to improve nursing efficiency by succinctly communicating health trends, thus alleviating workload. The system's potential to augment care by preempting health declines was acknowledged. To fully realize its benefits, further research is warranted to explore its direct impact on health outcomes and the factors influencing technology acceptance in eldercare.

Not all patients at risk for opioid overdose are prescribed naloxone when discharged from the emergency department or hospital. Clinical decision support (CDS) can be used to promote clinical best practices, such as naloxone prescribing; however, it may be ignored due to knowledge deficiencies or alert fatigue. Assess the effect of academic detailing on responses to a CDS alert recommending a naloxone prescription for patients at risk of opioid overdose. A pre/postquality improvement study of 2,161 active providers at a 400-bed academic medical center. The first intervention was an educational email to all providers. The second intervention was individual emails to 150 providers who infrequently ordered naloxone in response to the alert. The main outcome measure was prescription-to-alert ratios, defined as the number of naloxone prescriptions signed in response to the alert divided by the number of times the alert fired. The first academic detailing intervention resulted in a prescription-to-alert ratio increase from 32.6 to 51.7%, a 19.1% absolute increase when comparing the approximately 8 months before and after the email was sent (95% confidence interval [CI]: 16.3-21.9%, p < 0.001). The second intervention resulted in an increased prescription-to-alert ratio from 9.3 to 50.6%, an absolute increase of 41.3% when comparing the nearly 8 months before and after the emails were sent (95% CI: 36.9-45.7%, p < 0.001). Improvements were seen across all services and all provider roles, particularly for advanced practice providers, and were sustained for 8 months. Academic detailing can be used to augment responses to CDS for patients with opioid dependence. Further study is needed to see if this effect can be replicated with CDS for other high priority conditions, and whether academic detailing with one alert might improve responses to other alerts as well, potentially decreasing alert fatigue.

Engagement of clinicians who understand clinical workflows and technology constraints can accelerate the development and implementation of better electronic health record (EHR) designs that improve quality and reduce burnout. Provider builder programs can accelerate clinical informatics education for a broader coalition of clinical specialties. In this State of the Art/Best Practice paper, we aim to (1) propose a provider builder maturity model informed by the experience of three institutions using a single EHR vendor (Epic Systems) and (2) describe the program elements and relationships necessary to advance along this model to yield organizational benefits. We used a modified version of the Glaser State-of-the-Art approach, gathering consensus among a small group of experts at institutions with successful provider builder programs. The model was updated through meetings with a larger group of experts and then feedback from presentation at national conferences and the American Medical Informatics Association's Maturity Model Working Group. The final maturity model describes the characteristics and suggested next steps beginning from Planting the Seed (Stage 0) and progressing through Lone Wolves (Stage 1), a Community of Builders (Stage 2), Organizational Structure (Stage 3), a Council of Builders (Stage 4), and Informatics in the Room Where it Happens (Stage 5). We also describe the journeys of three organizations through these stages. A provider builder maturity model can help guide organizations on their journey engaging clinicians in collaborative EHR design to promote quality and safety and reduce burnout.