Objective:To determine and evaluate the accuracy of methods physicians use to detect diagnostic criteria for pediatric hypertension [hypertensive blood pressures (BPs) on three or more occasions] in electronic health records (EHRs).Methods:Methods used by pediatric-trained physicians (n = 12) to detect diagnostic criteria for hypertension in a simulation using a child's EHR data were directly observed, timed, and evaluated for accuracy. All physicians were given the same information regarding diagnostic criteria to eliminate knowledge gaps. Then, computer modeling and EHR data from 41 654 3-18-year-olds were used to simulate and compare the accuracy of detecting hypertension criteria using an observed-shorthand method vs. the guideline-recommended/gold-standard method.Results:No physician used the guideline-recommended method of determining multiple time-of-care hypertension thresholds for child age/height at the time of each BP measure. One physician estimated the child's BP diagnosis without computing thresholds; 11 of 12 physicians determined the child's hypertension threshold from age/height data at the time of a current visit and applied/imputed this threshold to BP measured at all visits (current-visit threshold used to assess historical-visit BPs) to detect three separate BP elevations. Physicians took 2.3 min (95% confidence interval, 1.5-3.0) to declare a diagnosis. Sensitivity was 83.1% when applying the current-visit threshold to detect the guideline-recommended-BP-threshold diagnosis using EHR data. Specificity and positive-predictive/negative-predictive values ranged from 98.5 to 99.9%.Conclusion:Physicians applied a shorthand method to evaluate pediatric BPs. Computer-simulated comparison of the shorthand and guideline methods using clinical data suggest the shorthand method could yield an inaccurate impression of a child's BP history in 17% of pediatric ambulatory visits.

Objective Rheumatoid arthritis (RA) disease activity assessment is critical for treatment decisions and treat to target (T2T) outcomes. Utilization of the electronic medical record (EMR) and techniques to improve the routine capture of disease activity measures in clinical practice are not well described. We leveraged a Lean Six Sigma (LSS) approach, a data‐driven five‐step process improvement and problem‐solving methodology, coupled with EMR modifications to evaluate improvement in disease activity documentation and patient outcomes. Methods A RA registry was established, and structured fields for Routine Assessment of Patient Index Data (RAPID3) and Clinical Disease Activity Index (CDAI) were built in the EMR, along with a dashboard to display provider performance rates. An initial rapid‐cycle improvement intervention was launched, and subsequent LSS improvement cycles helped in standardization of clinic workflow, modifying provider behaviors, and motivating better documentation practices. Trends related to CDAI score categories were compared over time using run charts. Results Our project included 1322 patients with RA and 10 241 encounters between April 2016 and December 2019. Initially, RAPID3 completion rates increased from 16% to 50%, and CDAI from 15% to 44% from the RCI intervention. Post LSS intervention, the RAPID3 rate increased to more than 90% (sustained at 85%), and CDAI rate increased to more than 80% (sustained at 72%). The patients in the low disease/remission category increased from 54% to 66% (p < 0.001), and those in the high disease category decreased from 15% to 7% (p < 0.001), demonstrating improved T2T outcomes. Conclusion Combining EMR modifications with systems redesign utilizing LSS approach led to impressive and sustained improvement in disease activity documentation and T2T outcomes.

INTRODUCTION:The United States Preventative Services Task Force recommendation against prostate-specific antigen (PSA) screening came in 2012, a time when many new primary care providers (PCPs) had been trained in the PSA screening era. We examined the differential effect of the recommendation on PCPs' PSA screening by physician seniority and evaluated the impact of their individual stated opinions on their screening practices. METHODS:We reviewed 54,684 PCP-directed PSA orders within a tertiary care academic institution from January 2010 to July 2015. Relative proportions of PSA orders per overall unique male ambulatory clinic volume were assessed for the periods of January 1, 2010 to December 31, 2011 (first period) and January 1, 2013 to July 31, 2015 (second period). A survey was subsequently sent to providers in the cohort assessing their attitudes toward the United States Preventative Services Task Force recommendation and responses were compared to physician seniority and actual PSA ordering habits. RESULTS:Of 88 total PCPs assessed, 22 met criteria for inclusion. Overall unique male nononcology care patients were 88,558 for the first period and 140,173 for the second period. Overall proportion of unique male patients screened did not change and proportion of overall unique male patients screened vs. time since residency demonstrated a significant negative trend (R2 = 0.308, P = 0.007, slope of trend line -0.000005). A subsequent survey revealed no correlation of any aspect of the questionnaire with actual real-world screening practice but did note a paradoxical positive association between physician seniority and stated PSA use. CONCLUSION:From January 2010 to July 2015 PSA screening did not change greatly for providers in continuous practice throughout the period. Time since residency completion was significantly associated with screening proportionally fewer men. Provider opinion did not appear to have a strong influence on actual physician practice. These findings further inform future efforts to alter PSA screening.

Background Defining clinical conditions from electronic health record (EHR) data underpins population health activities, clinical decision support, and analytics. In an EHR, defining a condition commonly employs a diagnosis value set or grouper. For constructing value sets, Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) offers high clinical fidelity, a hierarchical ontology, and wide implementation in EHRs as the standard interoperability vocabulary for problems. Objective This article demonstrates a practical approach to defining conditions with combinations of SNOMED CT concept hierarchies, and evaluates sharing of definitions for clinical and analytic uses. Methods We constructed diagnosis value sets for EHR patient registries using SNOMED CT concept hierarchies combined with Boolean logic, and shared them for clinical decision support, reporting, and analytic purposes. Results A total of 125 condition-defining standard SNOMED CT diagnosis value sets were created within our EHR. The median number of SNOMED CT concept hierarchies needed was only 2 (25th-75th percentiles: 1-5). Each value set, when compiled as an EHR diagnosis grouper, was associated with a median of 22 International Classification of Diseases (ICD)-9 and ICD-10 codes (25th-75th percentiles: 8-85) and yielded a median of 155 clinical terms available for selection by clinicians in the EHR (25th-75th percentiles: 63-976). Sharing of standard groupers for population health, clinical decision support, and analytic uses was high, including 57 patient registries (with 362 uses of standard groupers), 132 clinical decision support records, 190 rules, 124 EHR reports, 125 diagnosis dimension slicers for self-service analytics, and 111 clinical quality measure calculations. Identical SNOMED CT definitions were created in an EHR-agnostic tool enabling application across disparate organizations and EHRs. Conclusion SNOMED CT-based diagnosis value sets are simple to develop, concise, understandable to clinicians, useful in the EHR and for analytics, and shareable. Developing curated SNOMED CT hierarchy-based condition definitions for public use could accelerate cross-organizational population health efforts, smarter EHR feature configuration, and clinical-translational research employing EHR-derived data.

BACKGROUND:Although elevated glucose values are strongly associated with undiagnosed diabetes, they are frequently overlooked. Patient, provider, and system factors associated with failure to follow-up elevated glucose values in electronic medical records (EMRs) are not well described. METHODS:We conducted a chart review in a comprehensive EMR with a patient portal and results management features. Established primary care patients with no known diagnosis of diabetes and ≥ 1 glucose value >125 mg/dL were included. Follow-up failure was defined as (1) no documented comment on the glucose value or result communication to the patient within 30 days or (2) no hemoglobin A1c (HbA1c) ordered within 30 days or resulted within 12 months. Associations were examined using Wilcoxon and χ2 tests. RESULTS:Of 150 charts reviewed, 97 met inclusion criteria. The median glucose was 133 mg/dL, and 20% of patients had multiple values >125 mg/dL. Only 36% of elevated glucose values were followed up. No associations were observed between patient characteristics, diabetes risk factors, or provider characteristics and follow-up failures. Automated flagging of glucose values ≥140 mg/dL by highlighting them red in the EMR was not associated with improved follow-up (46% vs 32%; P = .19). Even when follow-up occurred (n = 35), only 31% completed gold standard diabetes testing (HbA1c) within 12 months. Of the resulted HbA1c tests (n = 11), 55% were in the prediabetes range (5.7%-6.4%). CONCLUSIONS:Two-thirds of elevated glucose values were not followed up, despite EMR features facilitating results management. Greater understanding of the results management process and improved EMR functionalities to support results management are needed.

OBJECTIVES:To determine the frequency of serious pulmonary and hepatic adverse events (AEs) in persons aged 65 and older prescribed nitrofurantoin. DESIGN:Retrospective electronic health record (EHR) audit of nitrofurantoin prescriptions and associated AEs. SETTING:Urban academic medical center. PARTICIPANTS:All inpatients and outpatients aged 65 and older prescribed nitrofurantoin from January 1, 2010, to December 31, 2014. MEASUREMENTS:The number of nitrofurantoin prescriptions and pulmonary and hepatic AEs associated with nitrofurantoin use was acquired by data extraction from EHRs. RESULTS:Of 3,400 individuals aged 65 and older prescribed nitrofurantoin during the study period, 641 were identified as possibly having one of five targeted symptoms or disease complications (pulmonary and hepatic) associated with nitrofurantoin. After a detailed chart audit, 89% were deemed to have no adverse reaction, 7% had a minor side effect or allergy, and 3.9% met criteria for suspicion of a nitrofurantoin-induced AE, five of whom were rated as being highly suspicious for nitrofurantoin toxicity; four of the five were identified with pulmonary toxicity and one with hepatotoxicity. Four of five of these individuals used nitrofurantoin chronically. CONCLUSION:Nitrofurantoin was prescribed for 3,400 individuals aged 65 and older during the 5-year study period. Serious side effects appeared to be uncommon, but chronic use appeared to be at greater risk.

Summary Background: Creation of a new electronic health record (EHR)-based registry often can be a “one-off” complex endeavor: first developing new EHR data collection and clinical decision support tools, followed by developing registry-specific data extractions from the EHR for analysis. Each development phase typically has its own long development and testing time, leading to a prolonged overall cycle time for delivering one functioning registry with companion reporting into production. The next registry request then starts from scratch. Such an approach will not scale to meet the emerging demand for specialty registries to support population health and value-based care. Objective: To determine if the creation of EHR-based specialty registries could be markedly accelerated by employing (a) a finite core set of EHR data collection principles and methods, (b) concurrent engineering of data extraction and data warehouse design using a common dimensional data model for all registries, and (c) agile development methods commonly employed in new product development. Methods: We adopted as guiding principles to (a) capture data as a byproduct of care of the patient, (b) reinforce optimal EHR use by clinicians, (c) employ a finite but robust set of EHR data capture tool types, and (d) leverage our existing technology toolkit. Registries were defined by a shared condition (recorded on the Problem List) or a shared exposure to a procedure (recorded on the Surgical History) or to a medication (recorded on the Medication List). Any EHR fields needed - either to determine registry membership or to calculate a registry-associated clinical quality measure (CQM) - were included in the enterprise data warehouse (EDW) shared dimensional data model. Extract-transform-load (ETL) code was written to pull data at defined “grains” from the EHR into the EDW model. All calculated CQM values were stored in a single Fact table in the EDW crossing all registries. Registry-specific dashboards were created in the EHR to display both (a) real-time patient lists of registry patients and (b) EDW-gener-ated CQM data. Agile project management methods were employed, including co-development, lightweight requirements documentation with User Stories and acceptance criteria, and time-boxed iterative development of EHR features in 2-week “sprints” for rapid-cycle feedback and refinement. Results: Using this approach, in calendar year 2015 we developed a total of 43 specialty chronic disease registries, with 111 new EHR data collection and clinical decision support tools, 163 new clinical quality measures, and 30 clinic-specific dashboards reporting on both real-time patient care gaps and summarized and vetted CQM measure performance trends. Conclusions: This study suggests concurrent design of EHR data collection tools and reporting can quickly yield useful EHR structured data for chronic disease registries, and bodes well for efforts to migrate away from manual abstraction. This work also supports the view that in new EHR-based registry development, as in new product development, adopting agile principles and practices can help deliver valued, high-quality features early and often.

You have accessJournal of UrologyProstate Cancer: Detection & Screening V1 Apr 2017PD40-11 IMPACT OF PRIMARY CARE PHYSICIAN FACTORS ON ADHERENCE TO UNITED STATES PREVENTATIVE SERVICES TASK FORCE RECOMMENDATION AGAINST PSA SCREENING Ryan Hutchinson, Nirmish Singla, Solomon Woldu, Abdulhadi Akhtar, Justin Haridas, Deepa Bhat, Claus Roehrborn, and Yair Lotan Ryan HutchinsonRyan Hutchinson More articles by this author , Nirmish SinglaNirmish Singla More articles by this author , Solomon WolduSolomon Woldu More articles by this author , Abdulhadi AkhtarAbdulhadi Akhtar More articles by this author , Justin HaridasJustin Haridas More articles by this author , Deepa BhatDeepa Bhat More articles by this author , Claus RoehrbornClaus Roehrborn More articles by this author , and Yair LotanYair Lotan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1751AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We examined the association of primary care physician (PCP) length of practice and prostate specific antigen (PSA) screening opinions on the differential effect of the United States Preventative Services Task Force (USPSTF) recommendation against PSA screening in 2012. METHODS 54,684 resulted PSA orders at our institution were reviewed from 2010-2015. Tests were excluded if they were performed by a non-PCP, if the provider ordered <4 tests/year, had a practice break >6 months, or if the provider was not employed at the institution for the entire period. Relative proportions of PSA orders per overall unique male ambulatory clinic volume were assessed for 2010-2011 (first period) and 2013-2015 (second period). Changes on a per-provider basis were assessed as a scatterplot, linear regression, and ANOVA. PCPs were surveyed on their attitudes towards the USPSTF recommendation and responses compared to physician seniority and actual PSA ordering habits. RESULTS 228,731 unique male non-oncology care patients were assessed. From an initial cohort of 88 PCPs, 22 PCPs met inclusion criteria. Mean time between completion of residency and beginning of period was 16 years (range 2-43). There was a significant inverse relationship (Fig 1) between years since completion of residency and change in the overall proportion of patients who underwent PSA screening, with more senior physicians noted to have a larger relative decline in screening rates after the USPSTF recommendation (R2 = 0.308, p=0.007). Eighteen PCPs completed a survey on the USPSTF and PSA which revealed no correlation between stated attitudes toward PSA screening and observed practice, however senior PCPs were more likely to claim greater current PSA screening (p=0.037). CONCLUSIONS Greater time since residency completion was significantly associated with screening proportionally fewer men over the period. PCPs' stated opinion on PSA screening did not appear to have a strong influence on actual observed practice. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e754 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Ryan Hutchinson More articles by this author Nirmish Singla More articles by this author Solomon Woldu More articles by this author Abdulhadi Akhtar More articles by this author Justin Haridas More articles by this author Deepa Bhat More articles by this author Claus Roehrborn More articles by this author Yair Lotan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Preventive services required for performance measurement often are completed in outside health systems and not captured in electronic medical records (EMRs). A before–after study was conducted to examine the ability of clinical decision support (CDS) to improve performance on preventive quality measures, capture clinician-reported services completed elsewhere, and patient/medical exceptions and to describe their impact on quality measurement. CDS improved performance on colorectal cancer screening, osteoporosis screening, and pneumococcal vaccination measures (P < .05) but not breast or cervical cancer screening. CDS captured clinician-reported services completed elsewhere (2% to 10%) and patient/medical exceptions (<3%). Compared to measures using only within-system data, including services completed elsewhere in the numerator improved performance: pneumococcal vaccine (73% vs 82%); breast (69% vs 75%), colorectal (58% vs 70%), and cervical cancer (53% vs 62%); and osteoporosis (72% vs 75%) screening (P < .05). Visit-based CDS can capture clinician-reported preventive services, and accounting for services completed elsewhere improves performance on quality measures.

You have accessJournal of UrologyProstate Cancer: Detection & Screening II1 Apr 2016PD09-02 PROSTATE CANCER SCREENING AND REFERRAL PATTERNS IN THE YEARS SURROUNDING THE UNITED STATES PREVENTATIVE SERVICES TASK FORCE RECOMMENDATION AGAINST PSA SCREENING IN ALL MEN Ryan Hutchinson, Abdulhadi Akhtar, Justin Haridas, Deepa Bhat, Claus Roehrborn, and Yair Lotan Ryan HutchinsonRyan Hutchinson More articles by this author , Abdulhadi AkhtarAbdulhadi Akhtar More articles by this author , Justin HaridasJustin Haridas More articles by this author , Deepa BhatDeepa Bhat More articles by this author , Claus RoehrbornClaus Roehrborn More articles by this author , and Yair LotanYair Lotan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2897AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In May 2012 the United States Preventative Services Task Force released final recommendations against prostatic-specific antigen (PSA) screening in all men. There have been conflicting reports regarding the impact of this recommendation on behavior of primary care providers (PCPs). We analyzed real-world whole-institution data on PSA incorporating actual patient demographics. METHODS Between 2010 and July 2015 there were 275,784 all-specialty unique ambulatory visits in men. PCPs ordered 17,315 PSA tests and 858 urology referrals. PSA orders were corrected for annual patient volume. Use of PSA and urologic referral were analyzed while stratifying for patient characteristics. Linear and quadratic regression analyses were performed. RESULTS Over the time period, number of PSAs ordered per ambulatory visit, referrals per ambulatory visit, age of patient at time of urologic referral and proportion of PSAs drawn outside of recommended age range did not significantly change. PSA value at time of referral increased significantly on linear (p = 0.022) and quadratic (p = 0.002) growth models. When analyzed by decade of life, no significant change was seen in PSAs ordered by age or in by-age referral proportion. CONCLUSIONS In the years surrounding the USPSTF recommendation, PSA ordering by institutional primary care providers did not change significantly. Patients receiving urologic referral were referred at progressively higher average PSA levels. The implications for prostate cancer outcomes from these trends warrant further research. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e234 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Ryan Hutchinson More articles by this author Abdulhadi Akhtar More articles by this author Justin Haridas More articles by this author Deepa Bhat More articles by this author Claus Roehrborn More articles by this author Yair Lotan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

BACKGROUND: Since the US Preventive Services Task Force (USPSTF) recommended against prostate-specific antigen (PSA) screening, there have been conflicting reports regarding the impact on the behavior of providers. This study analyzed real-world data on PSA ordering and referral practices in the years surrounding the recommendation. METHODS: A whole-institution sample of entered PSA orders and urology referrals was obtained from the electronic medical record. The study was performed at a tertiary referral center with a catchment in the southern United States. PSA examinations were defined as screening when they were ordered by providers with appointments in internal medicine, family medicine, or general internal medicine. Linear and quadratic regression analyses were performed, and joinpoint regression was used to assess for trend inflection points. RESULTS: Between January 2010 and July 2015, there were 275,784 unique ambulatory visits for men. There were 63,722 raw PSA orders, and 54,684 were evaluable. Primary care providers ordered 17,315 PSA tests and 858 urology referrals. The number of PSA tests per ambulatory visit, the number of referrals per ambulatory visit, the age at the time of the urology referral, and the proportion of PSA tests performed outside the recommended age range did not significantly change. The PSA value at the time of referral increased significantly (P5.022). Joinpoint analysis revealed no joinpoints in the analysis of total PSA orders, screening PSA tests, or examinations per 100 visits. CONCLUSIONS: In the years surrounding the USPSTF recommendation, PSA behavior did not change significantly. Patients were referred at progressively higher average PSA levels. The implications for prostate cancer outcomes from these trends warrant further research into provider variables associated with actual PSA utilization. (C) 2016 American Cancer Society.

Background: To determine whether patients found to have hematuria by their primary care physicians are evaluated according to best practice policy.Materials and methods: The University of Texas Southwestern Medical Center maintains institutional outpatient electronic medical records (EMR) that are used by all providers in all specialties. We conducted an Institutional Review Board approved observational study of patients found to have more than 5 red blood cells/high power field between March 2009 and February 2010.Results: There were 449 patients of whom the majority were female (82%), Caucasian (39%), with microscopic hematuria (MH) (85%). Almost 58% of patients were initially symptomatic with urinary symptoms or pain. Evaluation for the source of hematuria was limited and included imaging (35.6%), cystoscopy (9%, and cytology (7.3%). Only 36% of men and 8% of women were referred to a urologist. No abnormality was found in 32% and 51% of patients with gross hematuria and MH, respectively (P = 0.004). There were 4 bladder tumors and 1 renal mass detected. Male gender, ethnicity and gross (vs. microscopic) hematuria were associated with higher rate of urological referral. Advanced age, smoking, provider practice type, and the presence of urinary symptoms were not associated with an increase rate of urological referral. No additional cancers were diagnosed with 29-month follow-up.Conclusions: While urinalysis remains a common diagnostic tool, most cases of both microscopic and gross hematuria are not fully evaluated according to guidelines. Use of cystoscopy, cytology, and upper tract imaging is limited. Further studies will be needed to determine the extent of the problem and impact on morbidity and survival. (C) 2014 Elsevier Inc. All rights reserved.

Purpose: We evaluated the incidence of infectious complications requiring hospitalization after transrectal ultrasound guided prostate biopsy, comparing an augmented regimen of antibiotic prophylaxis to the standard regimen, and established cost-effectiveness at our center.Materials and Methods: Our standard antibiotic prophylaxis regimen consisted of 3 days of ciprofloxacin or Bactrim (TM) DS in the perioperative period. An increase in hospital admissions related to infection after transrectal ultrasound guided biopsy from January 2010 through December 2010 led us to initiate an augmented regimen of 3 days of ciprofloxacin or Bactrim DS in addition to 1 dose of intramuscular gentamicin before biopsy from January 2011 to December 2011. Urine and blood cultures along with bacterial susceptibilities were obtained at admission and compared between the 2 groups. Cost analysis was done to determine the cost-effectiveness of standard and augmented regimens.Results: The rate of hospitalization due to post-biopsy infections was 3.8% (11 patients among 290 biopsies) in 2010, which decreased to 0.6% (2 patients among 310 biopsies) in 2011 (p <0.001). Of the admitted patients who received standard prophylaxis, 73% had fluoroquinolone resistant Escherichia coli urinary infection and/or bacteremia and only 9% had strains resistant to gentamicin. Multivariate analysis showed that the standard regimen was significantly associated with hospital admission due to post-biopsy infection (HR 2.078 +/- 0.84, p = 0.013). The augmented regimen resulted in a cost savings of $15,700 per 100 patients compared to the standard regimen.Conclusions: The addition of gentamicin to current prophylactic regimens significantly reduced the rate of hospitalization for post-biopsy infectious complications and was shown to be cost-effective.

One purported advantage of electronic medical records (EMRs) is to improve patient care. This study uses a search of EMR to identify patients at risk for prostate cancer who were not evaluated by an urologist. The University of Texas Southwestern Medical Center (UTSW) has an institutional outpatient EMR that is used by all providers in all specialties. Since March 2009, all PSA tests were reported with specific interpretative comments including a recommendation for referral to urology for a PSA >2.5 ng ml−1. All PSA tests were performed on campus since institution of these recommendations were analyzed, and charts reviewed for all patients not seen in urology with a serum PSA >2.5 ng ml−1. Of the 2884 non-urology patients that had a serum PSA drawn between March 2009 and February 2010 at UTSW, 293 patients had a serum PSA >2.5 ng ml−1. Of these, 39 patients had known prostate cancer and were seeing an oncologist. There were 59 patients seeing urologists outside the institution. A total of 195 patients were not seen by an urologist and only 11 patients were recommended to see one but did not make an appointment. There were 151 patients with more than one PSA in the system, and of these 103 had a rise in PSA with a median rise of 0.53 ng ml−1 per year. EMR allows identification of patients at increased risk of prostate cancer who are not evaluated. Prospective studies are needed to identify ways to improve appropriate evaluation and detection of prostate cancer.