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With the emergence of the COVID-19 pandemic and shortage of adequate personal protective equipment (PPE), hospitals implemented inpatient telemedicine measures to ensure operational readiness and a safe working environment for clinicians. The utility and sustainability of inpatient telemedicine initiatives need to be evaluated as the number of COVID-19 inpatients is expected to continue declining. In this viewpoint, we describe the use of a rapidly deployed inpatient telemedicine workflow at a large academic medical center and discuss the potential impact on PPE savings. In early 2020, videoconferencing software was installed on patient bedside iPads at two academic medical center teaching hospitals. An internal website allowed providers to initiate video calls with patients in any patient room with an activated iPad, including both COVID-19 and non–COVID-19 patients. Patients were encouraged to use telemedicine technology to connect with loved ones via native apps or videoconferencing software. We evaluated the use of telemedicine technology on patients’ bedside iPads by monitoring traffic to the internal website. Between May 2020 and March 2021, there were a total of 1240 active users of the Video Visits website (mean 112.7, SD 49.0 connection events per month). Of these, 133 (10.7%) connections were made. Patients initiated 63 (47.4%) video calls with family or friends and sent 37 (27.8%) emails with videoconference connection instructions. Providers initiated a total of 33 (24.8%) video calls with the majority of calls initiated in August (n=22, 67%). There was a low level of adoption of inpatient telemedicine capability by providers and patients. With sufficient availability of PPE, inpatient providers did not find a frequent need to use the bedside telemedicine technology, despite a high census of patients with COVID-19. Compared to providers, patients used videoconferencing capabilities more frequently in September and October 2020. We did not find savings of PPE associated with the use of inpatient telemedicine.

BackgroundPatient portals tethered to electronic health records can improve patient experience, activation, and outcomes. However, adoption of inpatient portals has been challenging. One way to potentially increase inpatient portal usage is to integrate it with a room control (RC) app on a common tablet computer. ObjectiveThe aim of this study was to perform a retrospective analysis of patient usage of an RC app provided on tablet computers in patient rooms of our new inpatient tower. MethodsWe identified all patients who were admitted for >24 hours to our new inpatient tower over a 90-day period from September 1 to November 30, 2017. After excluding newborn patients from our analysis, we then identified patients who used the RC app at least one time during their admission. We linked these data to patient demographics (including age, sex, and race) and admitting service. We then performed univariable and multivariable logistic regression to assess patterns of RC app usage. ResultsA total of 3411 patients were admitted over the course of the study period; 2242/3411 (65.73%) used the RC app during their hospitalization. Compared with white patients, other/mixed/unknown race and Asian, Hawaiian, Pacific Islander, American Indian race were significantly associated with increased use of the RC app in a multivariable analysis. Increasing age was significantly associated with increased usage of the RC app. Usage of the RC app also varied by admitting services. Compared with general medicine, bone marrow transplant and general surgery patients had increased usage of the RC app. Conversely, critical care, medical specialties, neurology, surgical subspecialties, and obstetrics/gynecology were all associated with decreased usage of the RC app. ConclusionsOur study shows that one-third of patients are not using the RC app for critical room functions. Future initiatives to increase RC usage should take these populations into consideration. Contrary to common belief, older patients may use tablet-enabled RCs just as often, if not more often, than younger patients. Certain admitting services, such as neurology and surgical subspecialties, may have had lower usage rates owing to accessibility issues. Our study allows hospitals to tailor support for specific patient populations to increase RC app usage.

Hepatitis A virus (HAV) is transmitted through the fecal-oral route either by person-to-person contact or by ingestion of contaminated food or water (1). With the availability of the hepatitis A [...]

Objectives Effective communication amongst healthcare workers simultaneously promotes optimal patient outcomes when present and is deleterious to outcomes when absent. The advent of electronic health record (EHR)-embedded secure instantaneous messaging systems has provided a new conduit for provider communication. This manuscript describes the experience of one academic medical center with deployment of one such system (Secure Chat). Methods Data were collected on Secure Chat message volume from June 2017 to April 2023. Significant perideployment events were reviewed chronologically. Results After the first coronavirus disease 2019 lockdown in March 2020, messaging use increased by over 25 000 messages per month, with 1.2 million messages sent monthly by April 2023. Comparative features of current communication modalities in healthcare were summarized, highlighting the many advantages of Secure Chat. Conclusions While EHR-embedded secure instantaneous messaging systems represent a novel and potentially valuable communication medium in healthcare, generally agreed-upon best practices for their implementation are, as of yet, undetermined. [ABSTRACT FROM AUTHOR]

Objective Physicians of all specialties experienced unprecedented stressors during the COVID-19 pandemic, exacerbating preexisting burnout. We examine burnout's association with perceived and actionable electronic health record (EHR) workload factors and personal, professional, and organizational characteristics with the goal of identifying levers that can be targeted to address burnout. Materials and Methods Survey of physicians of all specialties in an academic health center, using a standard measure of burnout, self-reported EHR work stress, and EHR-based work assessed by the number of messages regarding prescription reauthorization and use of a staff pool to triage messages. Descriptive and multivariable regression analyses examined the relationship among burnout, perceived EHR work stress, and actionable EHR work factors. Results Of 1038 eligible physicians, 627 responded (60% response rate), 49.8% reported burnout symptoms. Logistic regression analysis suggests that higher odds of burnout are associated with physicians feeling higher level of EHR stress (odds ratio [OR], 1.15; 95% confidence interval [CI], 1.07–1.25), having more prescription reauthorization messages (OR, 1.23; 95% CI, 1.04–1.47), not feeling valued (OR, 3.38; 95% CI, 1.69–7.22) or aligned in values with clinic leaders (OR, 2.81; 95% CI, 1.87–4.27), in medical practice for ≤15 years (OR, 2.57; 95% CI, 1.63–4.12), and sleeping for <6 h/night (OR, 1.73; 95% CI, 1.12–2.67). Discussion Perceived EHR stress and prescription reauthorization messages are significantly associated with burnout, as are non-EHR factors such as not feeling valued or aligned in values with clinic leaders. Younger physicians need more support. Conclusion A multipronged approach targeting actionable levers and supporting young physicians is needed to implement sustainable improvements in physician well-being. [ABSTRACT FROM AUTHOR]

Introduction Electronic referral (e-referral) to quitlines helps connect tobacco-using patients to free, evidence-based cessation counseling. Little has been published about the real-world implementation of e-referrals across U.S. health systems, their maintenance over time, and the outcomes of e-referred patients. Aims and Methods Beginning in 2014, the University of California (UC)-wide project called UC Quits scaled up quitline e-referrals and related modifications to clinical workflows from one to five UC health systems. Implementation strategies were used to increase site readiness. Maintenance was supported through ongoing monitoring and quality improvement programs. Data on e-referred patients (n = 20 709) and quitline callers (n = 197 377) were collected from April 2014 to March 2021. Analyses of referral trends and cessation outcomes were conducted in 2021–2022. Results Of 20 709 patients referred, the quitline contacted 47.1%, 20.6% completed intake, 15.2% requested counseling, and 10.9% received it. In the 1.5-year implementation phase, 1813 patients were referred. In the 5.5-year maintenance phase, volume was sustained, with 3436 referrals annually on average. Among referred patients completing intake (n = 4264), 46.2% were nonwhite, 58.8% had Medicaid, 58.7% had a chronic disease, and 48.8% had a behavioral health condition. In a sample randomly selected for follow-up, e-referred patients were as likely as general quitline callers to attempt quitting (68.5% vs. 71.4%; p =.23), quit for 30 days (28.3% vs. 26.9%; p =.52), and quit for 6 months (13.6% vs. 13.9%; p =.88). Conclusions With a whole-systems approach, quitline e-referrals can be established and sustained across inpatient and outpatient settings with diverse patient populations. Cessation outcomes were similar to those of general quitline callers. Implications This study supports the broad implementation of tobacco quitline e-referrals in health care. To the best of our knowledge, no other paper has described the implementation of e-referrals across multiple U.S. health systems or how they were sustained over time. Modifying electronic health records systems and clinical workflows to enable and encourage e-referrals, if implemented and maintained appropriately, can be expected to improve patient care, make it easier for clinicians to support patients in quitting, increase the proportion of patients using evidence-based treatment, provide data to assess progress on quality goals, and help meet reporting requirements for tobacco screening and prevention. [ABSTRACT FROM AUTHOR]

We applied the event-related brain potential (ERP) technique to investigate the involvement of two neuromodulatory systems in learning and decision making: The locus coeruleus-norepinephrine (LC-NE) system and the mesencephalic dopamine system (DA system). We have previously presented evidence that the N2, a negative deflection in the ERP elicited by task-relevant events that begins approximately 200 ms after onset of the eliciting stimulus and that is sensitive to low-probability events, is a manifestation of cortex-wide noradrenergic modulation recruited to facilitate the processing of unexpected stimuli (Warren, Tanaka, & Holroyd, in press). Further, Holroyd and Coles (2002) proposed that the impact of DA reinforcement learning signals on the anterior cingulate cortex (ACC) produces a component of the ERP called the feedback-related negativity (FRN). The N2 and the FRN share a similar time range, a similar topography, and similar antecedent conditions. We varied factors related to the degree of cognitive deliberation across a series of experiments to dissociate these two ERP components. Across four experiments we varied the demand for a deliberative strategy, from passively watching feedback, to more complex/challenging decision tasks. Consistent with our predictions, the FRN was largest in the experiment involving active learning and smallest in the experiment involving passive learning whereas the N2 exhibited the opposite effect. Within each experiment, when subjects attended to color, the N2 was maximal at frontal-central sites, and when they attended to sex it was maximal over lateral-occipital areas, whereas the topology of the FRN was frontal-central in both task conditions. We conclude that both the DA system and the LC-NE system act in concert when learning from rewards that vary in expectedness, but that the DA system is relatively more exercised when subjects are relatively more engaged by the learning task.

Background: The authors draw upon their experience with a successful, enterprise-level, telemedicine program implementation to present a "How To" paradigm for other academic health centers that wish to rapidly deploy such a program in the setting of the COVID-19 pandemic. The advent of social distancing as essential for decreasing viral transmission has made it challenging to provide medical care. Telemedicine has the potential to medically undistance health care providers while maintaining the quality of care delivered and fulfilling the goal of social distancing. Methods: Rather than simply reporting enterprise telemedicine successes, the authors detail key telemedicine elements essential for rapid deployment of both an ambulatory and inpatient telemedicine solution. Such a deployment requires a multifaceted strategy: (1) determining the appropriateness of telemedicine use, (2) understanding the interface with the electronic health record, (3) knowing the equipment and resources needed, (4) developing a rapid rollout plan, (5) establishing a command center for post go-live support, (6) creating and disseminating reference materials and educational guides, (7) training clinicians, patients, and clinic schedulers, (8) considering billing and credentialing implications, (9) building a robust communications strategy, and (10) measuring key outcomes. Results: Initial results are reported, showing a telemedicine rate increase to 45.8% (58.6% video and telephone) in just the first week of rollout. Over a 5-month period, the enterprise has since conducted over 119,500 ambulatory telemedicine evaluations (a 1,000-fold rate increase from the pre-COVID-19 time period). Conclusion: This article is designed to offer a "How To" potential best practice approach for others wishing to quickly implement a telemedicine program during the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Objective: To describe the implementation of technological support important for optimizing clinical management of the COVID-19 pandemic.Materials and Methods: Our health system has confirmed prior and current cases of COVID-19. An Incident Command Center was established early in the crisis and helped identify electronic health record (EHR)-based tools to support clinical care.Results: We outline the design and implementation of EHR-based rapid screening processes, laboratory testing, clinical decision support, reporting tools, and patient-facing technology related to COVID-19.Discussion: The EHR is a useful tool to enable rapid deployment of standardized processes. UC San Diego Health built multiple COVID-19-specific tools to support outbreak management, including scripted triaging, electronic check-in, standard ordering and documentation, secure messaging, real-time data analytics, and telemedicine capabilities. Challenges included the need to frequently adjust build to meet rapidly evolving requirements, communication, and adoption, and to coordinate the needs of multiple stakeholders while maintaining high-quality, prepandemic medical care.Conclusion: The EHR is an essential tool in supporting the clinical needs of a health system managing the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Objective: The Safety Assurance Factors for EHR Resilience (SAFER) guides were released in 2014 to help health systems conduct proactive risk assessment of electronic health record (EHR)- safety related policies, processes, procedures, and configurations. The extent to which SAFER recommendations are followed is unknown.Methods: We conducted risk assessments of 8 organizations of varying size, complexity, EHR, and EHR adoption maturity. Each organization self-assessed adherence to all 140 unique SAFER recommendations contained within 9 guides (range 10-29 recommendations per guide). In each guide, recommendations were organized into 3 broad domains: "safe health IT" (total 45 recommendations); "using health IT safely" (total 80 recommendations); and "monitoring health IT" (total 15 recommendations).Results: The 8 sites fully implemented 25 of 140 (18%) SAFER recommendations. Mean number of "fully implemented" recommendations per guide ranged from 94% (System Interfaces-18 recommendations) to 63% (Clinical Communication-12 recommendations). Adherence was higher for "safe health IT" domain (82.1%) vs "using health IT safely" (72.5%) and "monitoring health IT" (67.3%).Conclusions: Despite availability of recommendations on how to improve use of EHRs, most recommendations were not fully implemented. New national policy initiatives are needed to stimulate implementation of these best practices. [ABSTRACT FROM AUTHOR]

Precision Medicine involves the delivery of a targeted, personalized treatment for a given patient. By harnessing the power of electronic health records ( EHRs), we are increasingly able to practice precision medicine to improve patient outcomes. In this article, we introduce the scientific community at large to important building blocks for personalized treatment, such as terminology standards that are the foundation of the EHR and allow for exchange of health information across systems. We briefly review different types of clinical decision support ( CDS) and present the current state of CDS, which is already improving the care patients receive with genetic profile-based tailored recommendations regarding diagnostic and treatment plans. We also report on limitations of current systems, which are slowly beginning to integrate new genomic data into patient records but still present many challenges. Finally, we discuss future directions and how the EHR can evolve to increase the capacity of the healthcare system in delivering Precision Medicine at the point of care. WIREs Syst Biol Med 2017, 9:e1378. doi: 10.1002/wsbm.1378 For further resources related to this article, please visit the . [ABSTRACT FROM AUTHOR]

Background Stroke is a worldwide problem with a limited number of approved treatments. Obtaining informed consent for acute stroke therapy is complicated by the breadth of information that must be communicated in a short period of time, the hectic nature of the emergency environment, the possible lack of understanding by the patient and/or family, and the critically time-sensitive nature of treatment for stroke. Complicating matters even further, patients are often unable to consent for themselves, placing the burden on surrogates to infer patients' wishes regarding treatment, and potentially limiting acute treatment by practitioners. Innovation An advance directive for acute stroke therapy was created, entitled COAST (Coordinating Options for Acute Stroke Therapy). This clinical initiative is being piloted at a large comprehensive stroke center, including the development of the advance directive form, integration of the form with electronic medical records, training healthcare providers, and outreach to patients. Conclusions COAST is an advance directive for stroke designed to make stroke care more efficient, optimize patients' autonomy, improve the quality of healthcare, and streamline the ethical management of complex care decisions in acute stroke. The inherent benefit of COAST is in providing patients and their families with more information regarding stroke and its treatment options, allowing them to take a more active role in their care. [ABSTRACT FROM AUTHOR]

This Viewpoint discusses mobile device–based personal health records, the challenges of making the devices interoperable with existing health care information systems, and the prospect that incorporation of smartphone personal health records might improve patient outcomes, lower costs, and improve health care quality. [ABSTRACT FROM AUTHOR]

Patients' journeys across the care continuum can be improved with patient-centered technology integrated into the care process. Misaligned financial incentives, change management challenges, and privacy concerns are some of the hurdles that have prevented health systems from deploying technology that engages patients along the care continuum. Despite these sociotechnical challenges, some health care organizations have developed innovative approaches to engaging patients. We describe promising technology-enabled consumer engagement practices at two community-based delivery organizations and two academic medical centers to demonstrate the approaches, sociotechnical challenges, and outcomes associated with their implementation. Leadership commitment and payer policies that align with the quadruple aim--enhancing patient experience, improving population health, reducing costs, and improving the work life of health care providers--would encourage further deployment and lead to greater consumer engagement along the care continuum. [ABSTRACT FROM AUTHOR]