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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.

ImportanceProcedural proficiency is a core competency for graduate medical education; however, procedural reporting often relies on manual workflows that are duplicative and generate data whose validity and accuracy are difficult to assess. Failure to accurately gather these data can impede learner progression, delay procedures, and negatively impact patient safety.ObjectiveTo examine accuracy and procedure logging completeness of a system that extracts procedural data from an electronic health record system and uploads these data securely to an application used by many residency programs for accreditation.Design, setting, and participantsThis quality improvement study of all emergency medicine resident physicians at University of California, San Diego Health was performed from May 23, 2023, to June 25, 2023.ExposuresAutomated system for procedure data extraction and upload to a residency management software application.Main outcomes and measuresThe number of procedures captured by the automated system when running silently compared with manually logged procedures in the same timeframe, as well as accuracy of the data upload.ResultsForty-seven residents participated in the initial silent assessment of the extraction component of the system. During a 1-year period (May 23, 2022, to May 7, 2023), 4291 procedures were manually logged by residents, compared with 7617 procedures captured by the automated system during the same period, representing a 78% increase. During assessment of the upload component of the system (May 8, 2023, to June 25, 2023), a total of 1353 procedures and patient encounters were evaluated, with the system operating with a sensitivity of 97.4%, specificity of 100%, and overall accuracy of 99.5%.Conclusions and relevanceIn this quality improvement study of emergency medicine resident physicians, an automated system demonstrated that reliance on self-reported procedure logging resulted in significant procedural underreporting compared with the use of data obtained at the point of performance. Additionally, this system afforded a degree of reliability and validity heretofore absent from the usual after-the-fact procedure logging workflows while using a novel application programming interface-based approach. To our knowledge, this system constitutes the first generalizable implementation of an automated solution to a problem that has existed in graduate medical education for decades.

OBJECTIVE: Physicians of all specialties experienced unprecedented stressors during the COVID-19 pandemic, exacerbating preexisting burnout. We examine burnouts 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

OBJECTIVES:  Effective communication between surgeons and anesthesiologists is critical for high-quality, safe, and efficient perioperative patient care. Despite widespread implementation of surgical safety checklists and time-outs, ineffective team communication remains a leading cause of patient safety events in the operating room. To promote effective communication, we conducted a pilot trial of a virtual huddle between anesthesiologists and surgeons. METHODS:  Attending anesthesiologists and surgeons at an academic medical center were recruited by email to participate in this feasibility trial. An electronic health record-based smartphone application was utilized to create secure group chats among trial participants the day before a surgery. Text notifications connected a surgeon/anesthesiologist pair in order to introduce colleagues, facilitate a preoperative virtual huddle, and enable open-ended, text message-based communication. A 5-point Likert scale-based survey with a free-text component was used to evaluate the utility of the virtual huddle and usability of the electronic platform. RESULTS:  A total of 51 unique virtual huddles occurred between 16 surgeons and 12 anesthesiologists over 99 operations. All postintervention survey questions received a positive rating (range: 3.50/5.00-4.53/5.00) and the virtual huddle was considered to be easy to use (4.47/5.00), improve attending-to-attending communication (4.29/5.00), and improve patient care (4.22/5.00). There were no statistically significant differences in the ratings between surgery and anesthesia. In thematic analysis of qualitative survey results, Participants indicated the intervention was particularly useful in interdisciplinary relationship-building and reducing room turnover. The huddle was less useful for simple, routine cases or when participation was one sided. CONCLUSION:  A preoperative virtual huddle may be a simple and effective intervention to improve communication and teamwork in the operating room. Further study and consideration of broader implementation is warranted.

IntroductionElectronic 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 methodsBeginning 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.ResultsOf 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).ConclusionsWith 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.ImplicationsThis 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.

BackgroundCosts vary substantially among electronic medical knowledge resources used for clinical decision support, warranting periodic assessment of institution-wide adoption.ObjectivesTo compare two medical knowledge resources, UpToDate and DynaMed Plus, regarding accuracy and time required to answer standardized clinical questions and user experience.MethodsA crossover trial design was used, wherein physicians were randomized to first use one of the two medical knowledge resources to answer six standardized questions. Following use of each resource, they were surveyed regarding their user experience. The percentage of accurate answers and time required to answer each question were recorded. The surveys assessed ease of use, enjoyment using the resource, quality of information, and ability to assess level of evidence. Tests of carry-over effects were performed. Themes were identified within open-ended survey comments regarding overall user experience.ResultsAmong 26 participating physicians, accuracy of answers differed by 4 percentage points or less. For all but one question, there were no significant differences in the time required for completion. Most participants felt both resources were easy to use, contained high quality of information, and enabled assessment of the level of evidence. A greater proportion of participants endorsed enjoyment of use with UpToDate (23/26, 88%) compared with DynaMed Plus (16/26, 62%). Themes from open-ended comments included interface/information presentation, coverage of clinical topics, search functions, and utility for clinical decision-making. The majority (59%) of open-ended comments expressed an overall preference for UpToDate, compared with 19% preferring DynaMed Plus.ConclusionDynaMed Plus is noninferior to UpToDate with respect to ability to achieve accurate answers, time required for answering clinical questions, ease of use, quality of information, and ability to assess level of evidence. However, user experience was more positive with UpToDate. Future studies of electronic medical knowledge resources should continue to emphasize evaluation of usability and user experience.

OBJECTIVE: The year 2020 was predominated by the coronavirus disease 2019 (COVID-19) pandemic. The objective of this article is to review the areas in which clinical information systems (CIS) can be and have been utilized to support and enhance the response of healthcare systems to pandemics, focusing on COVID-19. METHODS: PubMed/MEDLINE, Google Scholar, the tables of contents of major informatics journals, and the bibliographies of articles were searched for studies pertaining to CIS, pandemics, and COVID-19 through October 2020. The most informative and detailed studies were highlighted, while many others were referenced. RESULTS: CIS were heavily relied upon by health systems and governmental agencies worldwide in response to COVID-19. Technology-based screening tools were developed to assist rapid case identification and appropriate triaging. Clinical care was supported by utilizing the electronic health record (EHR) to onboard frontline providers to new protocols, offer clinical decision support, and improve systems for diagnostic testing. Telehealth became the most rapidly adopted medical trend in recent history and an essential strategy for allowing safe and effective access to medical care. Artificial intelligence and machine learning algorithms were developed to enhance screening, diagnostic imaging, and predictive analytics - though evidence of improved outcomes remains limited. Geographic information systems and big data enabled real-time dashboards vital for epidemic monitoring, hospital preparedness strategies, and health policy decision making. Digital contact tracing systems were implemented to assist a labor-intensive task with the aim of curbing transmission. Large scale data sharing, effective health information exchange, and interoperability of EHRs remain challenges for the informatics community with immense clinical and academic potential. CIS must be used in combination with engaged stakeholders and operational change management in order to meaningfully improve patient outcomes. CONCLUSION: Managing a pandemic requires widespread, timely, and effective distribution of reliable information. In the past year, CIS and informaticists made prominent and influential contributions in the global response to the COVID-19 pandemic.

During 2016-2018, San Diego County, California, USA, experienced one of the largest hepatitis A outbreaks in the United States in 2 decades. In close partnership with local healthcare systems, San Diego County Public Health led a public health response to the outbreak that focused on a 3-pronged strategy to vaccinate, sanitize, and educate. Healthcare systems administered nearly half of the vaccinations delivered in San Diego County. At University of California San Diego Health, the use of informatics tools assisted with the identification of at-risk populations and with vaccine delivery across outpatient and inpatient settings. In addition, acute care facilities helped prevent further disease transmission by delaying the discharge of patients with hepatitis A who were experiencing homelessness. We assessed the public health roles that acute care hospitals can play during a large community outbreak and the critical nature of ongoing collaboration between hospitals and public health systems in controlling such outbreaks.

ObjectiveTo describe the implementation of technological support important for optimizing clinical management of the COVID-19 pandemic.Materials and methodsOur 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.ResultsWe 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.DiscussionThe 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.ConclusionThe EHR is an essential tool in supporting the clinical needs of a health system managing the COVID-19 pandemic.

As healthcare organizations continue to grow and evolve, migrations from one commercial electronic health record (EHR) system to another are likely to become more common. However, little is known about front-line clinicians' and staff's perceptions of such changes. Our study addresses this gap through an organization-wide survey of employees immediately prior to the transition to a new commercial EHR. We found that almost all front-line clinicians and staff were aware of the upcoming migration, and that most felt positive or neutral about the change, with only about 11% indicating that they were uncomfortable with the migration. Reasons for discomfort included the beliefs that the new EHR will be more time consuming to use and that moving to a new EHR is too costly, as well as concerns about the migration process. Attitudes differed by demographic characteristics and satisfaction with the current EHR. We discuss the implications of these results.

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 WIREs website.

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.