Using Informatics to Improve Autism Screening in a Pediatric Primary Care Practice

Background: According to the most recent report from the CDC (2018), autism spectrum disorder (ASD) affects approximately one in 59 children in the United States (U.S.). In 2007, the American Academy of Pediatrics (AAP) issued a strong recommendation for all primary care providers to screen children for autism, using a validated tool, at the 18 and 24-month well-child visits, in order to begin the referral process for more formal testing, and intervention, promptly. Despite the strong stance of the AAP and evidence supporting the importance of early intervention for children with ASD, not all primary care providers are screening for ASD or developmental delay. Purpose: To improve the percentage of eligible children, presenting for 18 and 24 month wellchild visits in a pediatric primary care office, who are screened for ASD, by integrating the Modified Checklist for Autism in Toddlers (M-CHAT) screening tool into the electronic medical record with tablets. The specific aims were to increase the percentage of children screened and improve the documentation of the screens performed. Methods: This quality improvement project utilized a before-after quantitative design to support the improvement. Reports were obtained for three months prior to the implementation of the tablets and process change, and again for three months following the implementation. Manual chart reviews were also performed to verify the data from the reports. The definition used for complete screening for this project included 1) presence of the completed screen in the medical record, 2) provider documentation of the result, interpretation, and plan if indicated, and 3) CPT code entry for charge capture completed in the electronic medical record. Results: The results of the project revealed improvements in overall percentages of eligible children screened for autism at D-H Nashua Pediatrics. The percentage of complete screening increased from 64.7% to 73.9% following the implementation of the project, a change which is statistically significant (t=31.6105, df=16,p=0.05). Each individual element was also tracked and those results showed that 1) the completeness of provider documentation related to the screening increased from 93.6% to 96% (t=41.3321, df=16, p=0.05) and 2) the M-CHAT screen was present in the electronic health record (EHR) 98.9% of the time, which was an increase from 84.6% (t=295.4084, df=16, p=0.05). The charge capture completion rate remained statistically unchanged at 76.5% (t=0.4664, df=16, p=0.05). Additionally, only one screening was noted to be missed altogether, out of 280 eligible children. Prior to the project, there were four missed screenings (out of 156 eligible children) captured by the chart reviews conducted over three months prior to the implementation of the project. Overall, the results show that the project resulted in an increase the percentage of M-CHAT screening, an increase in the presence of source documentation in the electronic health record (EHR), and more complete provider documentation related to the screening

A Novel Approach for the Investigation of Multidisciplinary Collaboration using Social Network Analysis on Electronic Health Record Data

Social network analysis (SNA) is widely used to study multidisciplinary collaboration among healthcare professionals. Most of the earlier works have however relied on survey and observational data, which do not scale, and have been limited to only descriptive studies without providing insight on how to improve patient outcomes. However, since the widespread adoption of electronic health records (EHR) for care delivery, there has been progressively increasing interest in exploiting the rich collection of activity data that are captured in EHR systems. Ability to exploit EHR data has the potential to offer unprecedented capacity to study and improve multidisciplinary teams. Unfortunately, the methodologic approaches used so far have had significant limitations, which have hampered the realization of this promise. In this dissertation, I describe a novel, process-mining based methodologic approach for applying SNA to study multidisciplinary collaboration using metadata of clinical activities captured in EHR. First, I described the process of linking the EHR activity metadata to trauma registry data, which is rich in quality clinical and encounter data to produce a linked dataset that was used for the dissertation. Second, I described and applied the methodology to identify collaborative EHR usage patterns and correlated them to patient outcomes. I demonstrated that a more collaborative EHR usage pattern were associated with shorter emergency department length of stay, in the process, identifying meaningful insight that can be the focus of further research or intervention. And finally, I described and applied a modification of the methodology to identify and compare diurnal variations in collaborative care teams at various locations in the hospital. I demonstrated the presence of multi-team systems and described how the composition and collaborative patterns of the multi-team systems varied with the time of day. This dissertation provides a promising new direction for harnessing EHR data, and in doing so, sets the stage for future studies

A scoping review to inform care coordination strategies for youth with traumatic brain injuries: Care coordination tools

BACKGROUND: Children with traumatic brain injury (TBI) report unmet needs several years after their injury and may require long-term care. However, this chronic health condition is often only treated and monitored in the short-term. Care for young persons with TBI often relies on parents to manage their child’s complex care network. Effective care coordination can close these gaps and facilitate continuity of care for children with TBI. The purpose of this scoping review was to develop a better understanding of tools that improve care coordination for Children with Special Health Care Needs (CSHCN). This, in turn, can inform care for children with TBI. METHODS: A scoping review was conducted following the PRISMA framework and methodology. OVID/Medline, CINAHL, PsycINFO, EMBASE, and ERIC databases were searched for articles relevant to care coordination tools used with CSHCN. RESULTS: 21 articles met the criteria for inclusion in the review, and 6 major categories of care coordination tools were identified: telehealth, online health records and tools, care plans, inpatient discharge protocols, family training, and reminders. DISCUSSION: Studies examining telehealth, online tools, care plans, and family training care coordination interventions for CSHCN have shown positive outcomes and would be relevant strategies to improve the care of children with TBI. Future prospective research should investigate these tools to explore whether they might improve communication, reduce unmet needs, increase service access, and improve long-term outcomes for children with TBI

Electronic clinical decision support for children with minor head trauma and intracranial injuries: A sociotechnical analysis

BACKGROUND: Current management of children with minor head trauma (MHT) and intracranial injuries is not evidence-based and may place some children at risk of harm. Evidence-based electronic clinical decision support (CDS) for management of these children may improve patient safety and decrease resource use. To guide these efforts, we evaluated the sociotechnical environment impacting the implementation of electronic CDS, including workflow and communication, institutional culture, and hardware and software infrastructure, among other factors. METHODS: Between March and May, 2020 semi-structured qualitative focus group interviews were conducted to identify sociotechnical influences on CDS implementation. Physicians from neurosurgery, emergency medicine, critical care, and pediatric general surgery were included, along with information technology specialists. Participants were recruited from nine health centers in the United States. Focus group transcripts were coded and analyzed using thematic analysis. The final themes were then cross-referenced with previously defined sociotechnical dimensions. RESULTS: We included 28 physicians and four information technology specialists in seven focus groups (median five participants per group). Five physicians were trainees and 10 had administrative leadership positions. Through inductive thematic analysis, we identified five primary themes: (1) clinical impact; (2) stakeholders and users; (3) tool content; (4) clinical practice integration; and (5) post-implementation evaluation measures. Participants generally supported using CDS to determine an appropriate level-of-care for these children. However, some had mixed feelings regarding how the tool could best be used by different specialties (e.g. use by neurosurgeons versus non-neurosurgeons). Feedback from the interviews helped refine the tool content and also highlighted potential technical and workflow barriers to address prior to implementation. CONCLUSIONS: We identified key factors impacting the implementation of electronic CDS for children with MHT and intracranial injuries. These results have informed our implementation strategy and may also serve as a template for future efforts to implement health information technology in a multidisciplinary, emergency setting

Improving Patients\u27 Pain Management Through Proper Documentation

The aim of this project was to improve pain documentation on the Surgical Unit as a means to enhance caregiver communication on finding the best methods to manage patients’ pain. Effectively managing patients’ pain leads to better patient outcomes, increased patient and nurse satisfaction, and decreased length of hospitalization. The setting is a not-for-profit hospital in Southern California. The microsystem selected is the 32-bed capacity Surgical Unit that mainly admits pre- and post-surgical patients, but also accommodates non-surgical, telemetry, and trauma cases. To improve pain assessment documentation, collaboration was sought with the multidisciplinary team (IT department, clinical nurse specialists, and a nursing task force), to create an easier way for nurses to document a pain assessment with each administration of a pain medication. Initiating changes to the eMAR began late February 2016 and presented to the Surgical Unit staff during the first week of March 2016. Prior to implementation, chart audits were performed between January to February 2016 and found that assessments were only being performed 80% of the time. Changes to the methods of documentation in the eMAR, staff in-services, and the distribution of educational materials has raised compliance to 87%. Sustainability is expected to prevail as the intervention has stakeholder support, is in line with the institution’s procedures, and has perceived benefits from staff members

ICU Liberation Bundle: A Multidisciplinary Approach

Practice Problem: Patients with increased ventilator days see dramatic increases in their chances of developing healthcare-related conditions (HAC). Extended ICU stays increase the potential for problematic issues in patients\u27 physical, mental and spiritual health with short-and-long-term consequences. PICOT: The PICOT question that guided this project was looking at adult ventilated patients in a medical ICU (P) and what is the effect of initiating interdisciplinary ABCDEF-ICU liberation bundle rounding as (I) compared to no ICU liberation bundle rounding (C) has on the length of ventilator days (O) over eight weeks (T). Evidence: Evidence from quality studies and backing from the Society of Critical Care Medicine suggests that an interdisciplinary, holistic approach is ideal for ICU patients. Decreasing ventilator days includes using a bundle with steps ABCDEF addressed daily while patients are ventilated. Intervention: The ICU liberation bundle is a systematic approach to patient care. The bundle components: A-assess and manage pain, B-spontaneous awake and breathing trials, C-choice of pain and sedation management, D-assessing and managing ICU delirium, E-early mobility, and F-family involvement. Outcome: There was no clinical or statistical significance with this project. The ventilator days increased for the project time compared to previous data. Conclusion: Utilizing a multidisciplinary team approach and the ICU liberation bundle did not improve patient outcomes. This outcome was not consistent with current recommendations

Improving Patient Handover from the Pediatric Emergency Department to the Pediatric Intensive Care Unit

Patient safety can be at risk during registered nurse handover, particularly when transitioning between high risk areas. According to The Joint Commission (2017), a standardized transition process should be implemented during patient handover. The purpose of this paper was to evaluate the effect of a standardized process with a cognitive aid on handover between a pediatric emergency department and an intensive care unit. Objectives of the project were to decrease conversion time in the emergency department, increase standardized process utilization, and improve patient outcomes, registered nurse perception and satisfaction, and patient proxy satisfaction. This evidence-based quality improvement project took place in a free-standing children’s hospital, and involved registered nurses (N=168) and patients. The Plan, Do, Study, Act model was utilized to direct change. Outcomes were evaluated using pre- and post-data collected from surveys, report reviews, and organizational reports. Implementation of a standardized process with a cognitive aid had a statistically significant impact on use of the standardized handover process and registered nurse satisfaction without increasing transition time. Sustained increase in compliance with the process was achieved with use of the cognitive aid. Improvement was attributed to multiple, evidence-based, and tailored implementation strategies. Implementation of a cognitive aid within an established workflow and compliance tracking is likely to increase and sustain use of the standardized transition process during patient handover and improve registered nurse satisfaction

IMPROVING PCS 5.67 MEDITECH’S USER INTERFACE BY ADDING A “ONE-CLICK-ONE-SCREEN” ELECTRONIC PAGE

Medical organizations and physicians have been encouraged to implement different EHR systems. Initially these systems aimed to record, and store clinical data and improve its access and legibility. However, as these systems have become almost indispensable, users are demanding from these applications more complex tasks. Small practices and/or rural medical organizations often cannot afford to continuously upgrade their EHR systems or acquire modern systems. Research has shown that one way to solve this problem is to customize and add features that can facilitate user navigation. The purpose of this QI project was to investigate if integrating a “one-click-one-screen” electronic window displaying a snapshot of the most relevant and up-to-date patient information into PCS 5.67 Meditech was able to facilitate and improve data accessibility, information exchange, user satisfaction, patient care, and communication among the users. A pre-survey, given to 30 frequent users of PCS 5.67 Meditech, gathered their perception of the system’s UI. A “one-click one-screen” feature was designed however it was difficult to integrate it into the system’s UI because customization of this EHR system was complex beyond the local IT expertice. Nonetheless, the pre-survey data indicated that a significant number of PCS 5.67 Meditech users were dissatisfied with the performance of this EHR system. Additionally, the pre-survey data showed that the EHR system UI did not display clinical data in an efficient and user-friendly manner

Screening for Iron-Deficiency Anemia in the Pediatric Population (Ages 1-17) in Gonaïves, Haiti

Abstract Purpose: The purpose of this pilot project is to screen for iron-deficiency anemia in pediatric patients (ages 1-17) in a primary school in Gonaïves, Haiti. Patients with anemia will be treated with oral supplemental iron for a period of four weeks according to WHO guidelines (WHO, 2011). All students will be treated empirically for helminths per WHO guidelines, unless treated elsewhere in the last six months (WHO, 2017). Nutritional status will also be assessed using MUAC according to WHO guidelines (2017). Background Summary: Malnutrition contributes significantly to the problem of iron-deficiency anemia, with one in four children exhibiting stunting of growth due to moderate or severe malnutrition (USAID, 2018). Iron-deficiency anemia is a huge problem in Haiti, with a reported prevalence of 65% of children between the ages of six months- five years of age having the disease (EMMUS-V, 2012). Over the past 10 years in Haiti, the prevalence of iron-deficiency anemia in the pediatric population has increased from 61% to 66% (USAID, 2018). Some of the causes of iron-deficiency anemia can include malnutrition, chronic bleeding, helicobacter pylori or an absorption problem in the gastrointestinal tract (NIH, 2016). Iron-deficiency anemia is a disease that occurs when the body has a lower than normal number of red blood cells in the body. There is a reduction in both red blood cell mass and a drop in hemoglobin (Hgb) level (NIH, 2016). The World Health Organization defines anemia as a Hgb level of less than 11 for children 6-59 months of age, Hgb less than 11.5 for children 5-11, Hgb less than 12 for children 12-14 and non-pregnant women, and Hgb less than 13 for men ages 15 and older (WHO, 2011). Severe anemia includes Hgb level of less than 7 for children 6-59 months of age and Hgb level of less than 8 for children 5-14, non-pregnant women, and men ages 15 and older (WHO, 2011). It generally takes an extended period of time for iron-deficiency anemia to occur. The body needs iron to build healthy red blood cells. When the body is lacking in iron, it begins using up the iron stores and less red blood cells are produced (NIH, 2016). Infants, young children, and women of childbearing age are at highest risk for iron-deficiency anemia (NIH, 2016). Signs and symptoms can include fatigue, restless leg syndrome, cold hands and feet, pale skin, fatigue, shortness of breath and chest pain (NIH, 2016). Other symptoms can also include brittle nails, cracks in oral mucosa, tongue swelling, swelling of the spleen, and frequent infections (NIH, 2016). Infants and young children frequently exhibit behavioral problems, delayed growth and development, pica, and lack of appetite (NIH, 2016). If severe iron-deficiency anemia persists over an extended period of time, patients can also exhibit arrhythmias, enlarged heart, or heart failure (NIH, 2016). As discussed previously, the main causes of iron-deficiency anemia include malnutrition, chronic bleeding, helicobacter pylori or an absorption problem in the gastrointestinal tract (NIH, 2016). Currently, the environmental and lifestyle factors have affected increased rates of anemia. After the earthquake in 2010 in Haiti, the average number of meals per person has decreased from 2.46 meals per day to 1.58 meals per day (USAID, 2014). This is due to destruction of crops, inflation due to political instability, poor infrastructure, poor resource management, and increasing price of food. Due to the decreased number of meals there has been a decline in nutritional health and well-being. With the unemployment and underemployment rate hovering at 67% and the average yearly income of $1,800 USD it is very challenging for families to afford food (CIA, 2016). Intestinal parasites are a secondary environmental and lifestyle factor that can be treated. Intestinal parasites can create an absorption problem of micronutrients including iron in the gastrointestinal tract. An average of 50-70Project Plan: I propose a primary and secondary screening plan that will be used in pediatric health clinics or schools in Haiti with parental consent. It is essential that all patients be screened due to the enormous prevalence of iron-deficiency anemia in Haiti. The reported prevalence of 65$0.01 complete. The personnel will be trained on the device and educated about the cost of the supplies. Pediatric patients will be assessed by a nurse practitioner or medical doctor and treated for iron-deficiency anemia using the WHO guidelines criteria. The pediatric patient will receive liquid suspension or iron tablets for a period of four weeks as well as treatment for intestinal parasites should they meet the criteria for having iron-deficiency anemia. Education will be completed with the pediatric patient and their parent. They will be educated that they have the right to refuse medication at any time. Benefits of Hgb level screening for iron-deficiency anemia in developing countries and iron supplementation was proven in a recent meta-analysis to outweigh potential risks (Neuberger, et al., 2016). All pediatric patients will be treated empirically for helminths using broad-spectrum benzimidazoles per WHO guidelines, unless treated elsewhere in the last six months (WHO, 2017). Results: Benchmarking measures used were appropriate for this project. MUAC proved to be an appropriate screening tool. Of the 129 pediatric patients screened, no children were at risk for acute malnutrition (middle upper arm circumference 13.5 or greater). All receive an extra meal, five days a week while in school for free through The Rosemila Project Feeding Program. This could have contributed to this number. 104 out of 129 pediatric patients (80%) received preventative chemotherapy for helminths. The remaining 27 patients either did not return to clinic, already received treatment within the past six months, or refused. 10 pediatric patients either refused or were unable to obtain Hgb levels. Of the 119 pediatric patients where Hgb levels were obtained, 58% (n=69) were diagnosed with iron deficiency anemia and subsequently treated with oral iron supplementation for a period of four weeks. 4% (n=5) of the pediatric patients in this pilot study were diagnosed with severe anemia. The average Hgb level was 10.23 (n=119)