Patients in rural and underserved areas face significant barriers in accessing specialty care due to unavailability of services, geographic isolation, travel burden, and other cultural and socioeconomic factors.1 Pediatric dermatology is among the top three subspecialties that provides routine care for pediatric patients, however, shortage and maldistribution of pediatric dermatologists have remained a major hurdle for those living in remote and isolated areas.2 Pediatric dermatologists cluster in urban areas with high-patient volume and estimated wait times for new patients that often exceed 13 weeks, making access one of the major drivers of inequity for rural patients.2-4.

INTRODUCTION:The coronavirus disease 2019 (COVID-19) pandemic resulted in an unprecedented expansion in telehealth, but little is known about differential use of telehealth according to demographics, rurality, or insurance status.METHODS:We performed a cross-sectional analysis of 7742 family medicine encounters at a single USA institution in the initial month of the COVID-19 public health emergency (PHE). We compared the demographics of those using telehealth during the PHE to those with face-to-face visits during the same time period; we also compared the demographics of those using full audio-video to those using audio-only.RESULTS:The likelihood of any telehealth visit in the first 30 days of telehealth expansion was higher for women, those age 65 years and older, self-pay patients, and those with Medicaid and Medicare as primary payers. The likelihood of a telehealth visit was reduced for rural residence and Black or other races. Among all telehealth visits, the likelihood of a full audio-video telehealth visit was reduced for patients who were older, Black, from urban areas, or who were self-pay, Medicaid, or Medicare payer status.DISCUSSION:Significant disparities exist in telehealth use during the COVID-19 PHE by age, race, residence and payer.

Student run free health clinics (SRFCs) provide medical care to vulnerable populations in communities throughout the United States. The COVID-19 pandemic had a significant impact on the delivery of healthcare services and demanded a rapid adjustment in care delivery methods in both resource-rich and resource-poor settings. The aim of this study is to evaluate the impact of the pandemic on the management of chronic disease, specifically diabetes. Patients with diabetes who received care continuously throughout the pre-pandemic (face-to-face) and pandemic (telehealth) study periods at MedZou Community Health Center, a SRFC located in central Missouri, were evaluated. This sample of patients (n = 29) was evaluated on six quality measures including annual eye exams, blood pressure, hemoglobin A1c, chronic kidney disease monitoring, flu vaccination, and statin therapy. Overall diabetes care, as measured by the number of quality measures met per patient, decreased by 0.37 after the onset of the pandemic. The median COVID-era ranks were not statistically significantly different than the pre-pandemic ranks (z = 1.65, P = 0.099). Fewer patients received an influenza vaccination the year following the onset of the pandemic (10.3%) compared to the year before the pandemic (37.9%; difference in proportions 0.276, 95% CI 0.079, 0.473; p = 0.005). No other individual measures of diabetes care statistically differed significantly in the year after the pandemic began. Twenty-six (90%) patients received diabetes care using telehealth after the onset of the pandemic. Diabetes care using telehealth in a SRFC may be an acceptable alternative model when face-to-face visits are not feasible. Observed decreases in diabetes-related clinical quality measure performance warrant further study.

Background Provider prescribing practices contribute to an excess of opioid-related deaths in the United States. Clinical guidelines exist to assist providers with improving prescribing practices and promoting patient safety. Clinical decision support systems (CDSS) may promote adherence to these guidelines and improve prescribing practices. The aim of this project was to improve opioid guideline adherence, prescribing practices, and rates of opioid-related encounters through the implementation of an opioid CDSS. Methods A vendor-developed, provider-targeted CDSS package was implemented in a multi-location academic health center. An interrupted time-series analysis was performed, evaluating 30 weeks pre- and post-implementation time periods. Outcomes were derived from vendor-supplied key performance indicators and directly from the electronic health record (EHR) database. Opioid-prescribing outcomes included count of opioid prescriptions, morphine milligram equivalents per prescription, counts of opioids with concurrent benzodiazepines, and counts of short-acting opioids in opioid-naive patients. Encounter outcomes included rates of encounters for opioid abuse and dependence and rates of encounters for opioid poisoning and overdose. Guideline adherence outcomes included rates of provision of naloxone and documentation of opioid treatment agreements. Results The opioid CDSS generated an average of 1,637 alerts per week. Rates of provision of naloxone and opioid treatment agreements improved after CDSS implementation. Vendor-supplied prescribing outcomes were consistent with prescribing outcomes derived directly from the EHR, but all prescribing and encounter outcomes were unchanged. Conclusion A vendor-developed, provider-targeted opioid CDSS did not improve opioid-prescribing practices or rates of opioid-related encounters. The CDSS improved some measures of provider adherence to opioid-prescribing guidelines. Further work is needed to determine the optimal configuration of opioid CDSS so that opioid-prescribing patterns are appropriately modified and encounter outcomes are improved.

OBJECTIVES:Poor electronic health record (EHR) usability is associated with patient safety concerns, user dissatisfaction, and provider burnout. EHR certification requires vendors to perform user testing. However, there are no such requirements for site-specific implementations. Health care organizations customize EHR implementations, potentially introducing usability problems. Site-specific usability evaluations may help to identify these concerns, and "discount" usability methods afford health systems a means of doing so even without dedicated usability specialists. This report characterizes a site-specific discount user testing program launched at an academic medical center. We describe lessons learned and highlight three of the EHR features in detail to demonstrate the impact of testing on implementation decisions and on users. METHODS:Thirteen new EHR features which had already undergone heuristic evaluation and iterative design were evaluated over the course of three user test events. Each event included five to six users. Participants used think aloud technique. Measures of user efficiency, effectiveness, and satisfaction were collected. Usability concerns were characterized by the type of usability heuristic violated and by correctability. RESULTS:Usability concerns occurred at a rate of 2.5 per feature tested. Seventy percent of the usability concerns were deemed correctable prior to implementation. The first highlighted feature was moved to production despite low single ease question (SEQ) scores which may have predicted its subsequent withdrawal from production based on post implementation feedback. Another feature was rebuilt based on usability findings, and a new version was retested and moved to production. A third feature highlights an easily correctable usability concern identified in user testing. Quantitative usability metrics generally reinforced qualitative findings. CONCLUSION:Simplified user testing with a limited number of participants identifies correctable usability concerns, even after heuristic evaluation. Our discount usability approach to site-specific usability has a role in implementations and may improve the usability of the EHR for the end user.

Abstract Background In a prior study we identified leverage points for improving infective endocarditis (IE) outcomes at an academic medical center¹. We aimed to improve the rate of surgery for those with guideline-based indications for surgery by 50%. Methods We recorded outcomes and surgical indications for patients with IE from December 2018 to June 2020 and compared to our prior published data from January to December 2016, using similar criteria.¹ Changes implemented in the interim period included development of a multidisciplinary team (MDT) for IE that provided recurring conferences, participated in heart valve team case discussions, and promoted the use of a home-grown algorithmic clinical care pathway within the electronic health record to guide providers on the next steps in management. Primary outcomes were surgery or transfer to a higher center for surgery, and in-hospital death. Odds ratios were calculated using a multivariate logistic regression model including age and sex covariates. Results We identified 31 IE patients with guideline indications for surgery. Of those patients, 15(48.39%) were female, 15(48.4%) were 18 - 44 years of age, 8(25.8%) were 45 - 64 years, 8(25.8%) were >64 years, 28(90.3%) white, 2(6.4%) black, 1(3.2%) East Asian, 17(54.8%) were intravenous drug users. Prior to the intervention, 6 of 21 (28.6%) patients with indications underwent surgery or were transferred outside for surgery and 6 (28.6%) patients died. Post-intervention, 17 of 31 (54.8%) patients with indications underwent or were transferred for surgery, and 5 (16.1%) died. After adjustment for age and sex, compared to the pre-intervention period, the odds of surgery or transfer for surgery for patients in the post-intervention period was 4.88 (95% CI 1.20, 19.79, p=.027). The odds ratio for death among patients in the post-intervention period was 0.40 (95% CI 0.09, 1.69, p=0.21). Pre- and post-intervention outcomes for infective endocarditis patients Conclusion MDT team with continued educational and health IT interventions improved the number of surgeries performed for IE. 1. Regunath H, Vasudevan A, Vyas K, et al. A Quality Improvement Initiative: Developing a Multi-Disciplinary Team for Infective Endocarditis. Mo Med. 2019;116(4):291-296. Disclosures All Authors: No reported disclosures.

In this study we investigate the application of logistic regression to audit log data to identify novel differences in the electronic medical record (EMR) experience between primary care (PC), surgical (S), and non-surgical medical (NSM) specialty groups using logistic regression. While 12 of the 23 candidate features identified through subject matter expert interview were significant in the univariate model, many dropped below the level of significance in the multinomial model. The final model of best fit included only eight features. Total overall time in EMR and teamwork for orders were predictive for PC, while a higher percentage of documentation, patient discharge, and chart review time, in particular review of clinical notes, were more predictive for S and NSM specialty groups. This study provides single site evidence of significant EMR workflow differences between specialty groups as measured through audit log data.

SARS-CoV-2 pandemic has had significant impacts on the world. The longer the pandemic continues the more we learn about the virus behind it and the post-infection complications. SARS-CoV-2 infections have been associated with immune dysfunction and thyroid disease. The spectrum of thyroid disease reported spans from subacute thyroiditis to Hashimoto’s thyroiditis. We report a 16-years-old patient whose COVID-19 infection was followed by multiple complications including the appearance of symptomatic Graves’ disease. Laboratory analysis was significant for elevated TSH, low free thyroxine, and antibodies consistent with the diagnosis of Graves’ disease. This is the first case of Graves’ disease after COVID-19 infection to be reported and the first case of thyroid dysfunction secondary to COVID-19 infection reported in the pediatric population. The spectrum of thyroid and autoimmune disease following COVID-19 is discussed. Further research into the underlying pathology behind COVID-19 infection and immune dysfunction will lead to expediated diagnosis and improved patient outcomes.

Student run free clinics (SRFCs) fill a void in healthcare access for many communities and have been subject to unprecedented shifts in care delivery brought about by the coronavirus disease 2019 (COVID-19) pandemic. Our single-center institution serving uninsured patients in central Missouri switched from in-person visits to strictly telehealth visits with the onset of the pandemic. This study investigated the impact of the pandemic and the switch to telehealth on the clinic return rates by ethnicity, race, gender, rurality, and age. The pandemic led to a 47.4% reduction in the number of monthly patient encounters. Of the established SRFC population (N = 309), only 87 patients (28.2%) returned for a telehealth visit during the COVID-19 pandemic. Older patients (≥ 45 years old) were more likely to return (OR 1.71, 95% CI 1.02–2.85) for care via telehealth after the onset of the pandemic than younger patients (< 45 years old). No differences in the likelihood of returning for a telehealth visit were identified by race, ethnicity, gender, or rurality. Telehealth offers an effective solution to the complex problems faced by SRFCs during the COVID-19 pandemic and has not added barriers to care with regards to race, ethnicity, gender, or rurality at our SRFC.

CONTEXT:Hospitalization provides an opportunity to address end-of-life care (EoLC) preferences if patients at risk of death can be accurately identified while in the hospital. The modified Hospital One-Year Mortality Risk (mHOMR) uses demographic and admission data in a logistic regression algorithm to identify patients at risk of death one year from admission. OBJECTIVES:This project sought to validate mHOMR and identify superior models. METHODS:The mHOMR model was validated using historical data from an academic health system. Alternative logistic regression and random forest (RF) models were developed using the same variables. Receiver operating characteristic (ROC) and precision recall curves were developed, and sensitivity, specificity, and positive and negative predictive values were compared over a range of model thresholds. RESULTS:The RF model demonstrated higher area under the ROC curve (0.950, 95% CI 0.947 - 0.954) as compared to the logistic regression models (0.818 [95% CI 0.812 - 0.825] and 0.841 [95% CI 0.836 - 0.847]). Area under the precision recall curve was higher with the random forest model compared to the logistic regression models (0.863 vs. 0.458 and 0.494, respectively). Across a range of thresholds, the RF model demonstrated superior sensitivity, equivalent specificity, and higher positive and negative predictive values. CONCLUSION:A machine learning RF model, using common demographic and utilization data available on hospital admission, identified inpatients at risk of death more effectively than logistic regression models using the same variables. Machine learning models have promise for identifying admitted patients with elevated one-year mortality risk, increasing opportunities to prompt discussion of EoLC preferences.

Objectives Improving the usability of electronic health records (EHR) continues to be a focus of clinicians, vendors, researchers, and regulatory bodies. To understand the impact of usability redesign of an existing, site-configurable feature, we evaluated the user interface (UI) used to screen for depression, alcohol and drug misuse, fall risk, and the existence of advance directive information in ambulatory settings. Methods As part of a quality improvement project, based on heuristic analysis, the existing UI was redesigned. Using an iterative, user-centered design process, several usability defects were corrected. Summative usability testing was performed as part of the product development and implementation cycle. Clinical quality measures reflecting rolling 12-month rates of screening were examined over 8 months prior to the implementation of the redesigned UI and 9 months after implementation. Results Summative usability testing demonstrated improvements in task time, error rates, and System Usability Scale scores. Interrupted time series analysis demonstrated significant improvements in all screening rates after implementation of the redesigned UI compared with the original implementation. Conclusion User-centered redesign of an existing site-specific UI may lead to significant improvements in measures of usability and quality of patient care.

I ONCE TOOK PART IN A PRODUCTION of the Tom Stoppard play Dogg’s Hamlet, Cahoot’s Macbeth. In the first half I played Dogg, headmaster of an English public school that is rehearsing and then performing Hamlet. For the inner, performed, play I was Claudius (dying twice over in increasingly short versions of Shakespeare’s tragedy). Stoppard’s characters speak an invented language (also called Dogg and based on a tongue that Wittgenstein creates in his Philosophical Investigations), except when they are performing the words of Shakespeare’s play, and sometimes even then. This whole first half of Stoppard’s play is a wildly funny intellectual farce, and after the intermission the audience came back prepared to enjoy that same kind of farce when Cahoot’s Macbeth began. The second part begins, however, with the opening witch scene of Shakespeare’s Macbeth, played absolutely straight. The rest of the play is a rich mixture of farce and serious political drama.

Abstract Introduction Unnecessary and inappropriate laboratory testing contributes to increased health care costs, increases length of stay, and increases odds for blood product transfusion. The Choosing Wisely campaign recommends a judicious use of laboratory blood testing to combat iatrogenic anemia. Reducing the number of duplicate test orders may help address these issues. We evaluated duplicate order alert thresholds in our electronic health record for 10 common laboratory tests at an academic medical center. Methods In January 2019, alert intervals for 10 common inpatient laboratory tests (thyroid stimulating hormone, complete blood count, hemoglobin A1c, troponin, lactic acid, hemoglobin and hematocrit, urinalysis, vitamin D, urine beta HCG, and triglycerides) were adjusted to evidence-based, disease-specific thresholds. If a test was ordered within a timeframe shorter than this threshold, an alert interrupted the provider’s workflow. The provider was allowed to override the alert based on clinical judgment. This is a change from the previous settings, which alerted any test if ordered more frequently than 8 hours. Postintervention duplicate order alerts were compared to baseline rates and adjusted for number of inpatient discharges. Results In total, 914 orders were cancelled in 1 month as a result of tailored duplicate order alerts versus the baseline mean of 710 (95% CI, 633-786) and a predicted 552 (95% CI, 475-628) when adjusted for number of inpatient discharges, with the majority of cancelled orders being for CBC (530 accepted alerts). Overall, this reduction in unnecessary duplicate tests is equivalent to 3,092 mL of blood not collected from patients per month. Conclusion Tailoring duplicate order alert interval thresholds to evidence-based criteria helps reduce unnecessary testing, reduces costs, and may play an important role in reducing hospital-acquired anemia.

"The Creativity Challenge: How We Can Recapture American Innovation. Kim, K. H. (2016)." Roeper Review, 39(2), pp. 146–147

The Ball Fiber Optical Comb Demo is a lab-based system which is used to develop space applications for optical frequency combs. These developments utilize the broadband optical coherence of the frequency comb to expand the capabilities of ground test and orbital systems used for optical wave-front measurement, control of adaptive optics, precision ranging, and reference frequency stabilization. The work expands upon a NIST-developed all-fiber frequency comb that exhibits high stability in a compact, enclosed package.Previously demonstrated applications for frequency combs include: Spectroscopy, distance and velocity measurement, frequency conversion, and timing transfer. Results from the Ball system show the characterization and performance of a frequency comb system with a technological path-to-space. Demonstrations in high precision metrology and long distance ranging are also presented for application in adaptive and multi-body optical systems.

Frequency stabilized narrow line-width lasers have a broad range of applications including precision metrology, spectroscopy, atomic clocks and geodesy. This technology will be a key enabler to several proposed NASA science missions. Although lasers such as Q-switched Nd-YAG are now commonly used in space, other types of lasers - especially those with narrow linewidth - are still few in number and more development is required to advance their technology readiness.In this paper we discuss a reconfigurable laser frequency stabilization testbed, and end-to-end modeling to support system development. Two important features enabling testbed flexibility are that the controller, signal processing and interfaces are hosted on a field programmable gate array (FPGA) which has space-qualified equivalent parts, and secondly, fiber optic relay of the beam paths. Given the nonlinear behavior of lasers, FPGA implementation is a key system reliability aspect allowing on-orbit retuning of the control system and initial frequency acquisition. The testbed features a dual sensor system, one based upon a high finesse resonator cavity which provides relative stability through Pound-Drever-Hall (PDH) modulation and secondly an absolute frequency reference by dither locking to an acetylene gas cell (GC). To provide for differences between ground and space implementation, we have developed an end-to-end Simulink/Matlab (R)-based control system model of the testbed components including the important noise sources. This model is in the process of being correlated to the testbed data which then can be used for trade studies, and estimation of space-based performance and sensitivities. A 1530 nm wavelength semiconductor laser is used for this initial work.

Ball Aerospace & Technologies Corp. (BATC) has developed a Risley Beam Pointer (RBP) mechanism capable of agile slewing, accurate pointing and high bandwidth. The RBP is comprised of two wedged prisms that offer a wide Field of Regard (FOR) and may be manufactured and operated with diffraction limited optical quality. The tightly packaged mechanism is capable of steering a 4 inch beam over a 60° half angle cone with better than 60 μrad precision. Absolute accuracy of the beam steering is better than 1 mrad. The conformal nature of the RBP makes it an ideal mechanism for use on low altitude aircraft and unmanned aerial vehicles. Unique aspects of the opto-mechanical design include i) thermal compliance to maintain bearing preload and optical figure over a wide temperature range; and ii) packaging of a remote infrared sensor that periodically reports the temperature of both prisms for accurate determination of the index of refraction. The pointing control system operates each prism independently and employs an inner rate loop nested within an outer position loop. Mathematics for the transformation between line-of-sight coordinates and prism rotation are hosted on a 200 MHz microcontroller with just 516 KB of RAM.