Development and Validation of eRADAR: A Tool Using EHR Data to Detect Unrecognized Dementia.

ObjectivesEarly recognition of dementia would allow patients and their families to receive care earlier in the disease process, potentially improving care management and patient outcomes, yet nearly half of patients with dementia are undiagnosed. Our aim was to develop and validate an electronic health record (EHR)-based tool to help detect patients with unrecognized dementia (EHR Risk of Alzheimer's and Dementia Assessment Rule [eRADAR]).DesignRetrospective cohort study.SettingKaiser Permanente Washington (KPWA), an integrated healthcare delivery system.ParticipantsA total of 16 665 visits among 4330 participants in the Adult Changes in Thought (ACT) study, who undergo a comprehensive process to detect and diagnose dementia every 2 years and have linked KPWA EHR data, divided into development (70%) and validation (30%) samples.MeasurementsEHR predictors included demographics, medical diagnoses, vital signs, healthcare utilization, and medications within the previous 2 years. Unrecognized dementia was defined as detection in ACT before documentation in the KPWA EHR (ie, lack of dementia or memory loss diagnosis codes or dementia medication fills).ResultsOverall, 1015 ACT visits resulted in a diagnosis of incident dementia, of which 498 (49%) were unrecognized in the KPWA EHR. The final 31-predictor model included markers of dementia-related symptoms (eg, psychosis diagnoses, antidepressant fills), healthcare utilization pattern (eg, emergency department visits), and dementia risk factors (eg, cerebrovascular disease, diabetes). Discrimination was good in the development (C statistic = .78; 95% confidence interval [CI] = .76-.81) and validation (C statistic = .81; 95% CI = .78-.84) samples, and calibration was good based on plots of predicted vs observed risk. If patients with scores in the top 5% were flagged for additional evaluation, we estimate that 1 in 6 would have dementia.ConclusionThe eRADAR tool uses existing EHR data to detect patients with good accuracy who may have unrecognized dementia. J Am Geriatr Soc 68:103-111, 2019

Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients.

In December 2017, the National Academy of Neuropsychology convened an interorganizational Summit on Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients in Denver, Colorado. The Summit brought together representatives of a broad range of stakeholders invested in the care of older adults to focus on the topic of cognitive health and aging. Summit participants specifically examined questions of who should be screened for cognitive impairment and how they should be screened in medical settings. This is important in the context of an acute illness given that the presence of cognitive impairment can have significant implications for care and for the management of concomitant diseases as well as pose a major risk factor for dementia. Participants arrived at general principles to guide future screening approaches in medical populations and identified knowledge gaps to direct future research. Key learning points of the summit included: recognizing the importance of educating patients and healthcare providers about the value of assessing current and baseline cognition;emphasizing that any screening tool must be appropriately normalized and validated in the population in which it is used to obtain accurate information, including considerations of language, cultural factors, and education; andrecognizing the great potential, with appropriate caveats, of electronic health records to augment cognitive screening and tracking of changes in cognitive health over time

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

Organizing for Higher Performance: Case Studies of Organized Delivery Systems

Offers lessons learned from healthcare delivery systems promoting the attributes of an ideal model as defined by the Fund: information continuity, care coordination and transitions, system accountability, teamwork, continuous innovation, and easy access

HealthPartners: Consumer-Focused Mission and Collaborative Approach Support Ambitious Performance Improvement Agenda

Presents a case study of a nonprofit healthcare organization that exhibits the six attributes of an ideal healthcare delivery system as defined by the Fund, including information continuity, care coordination and transitions, and system accountability

Electronic Health Records and Support For Primary Care Teamwork

This study examined primary care practices' experiences using electronic health records (EHRs) as they strive to function as teams in patientcentered medical homes (PCMHs). We identify how EHRs facilitate and pose challenges to teamwork and how practices overcame such challenges. We describe solutions and identify opportunities to improve care processes as well as EHR functionalities and policies, to support teamwork

Overcoming Challenges to Teamwork in Patient-Centered Medical Homes: A Qualitative Study

There is emerging consensus that enhanced inter-professional teamwork is necessary for the effective and efficient delivery of primary care, but there is less practical information specific to primary care available to guide practices on how to better work as teams. The purpose of this study was to describe how primary care practices have overcome challenges to providing team-based primary care and the implications for care delivery and policy

Improving a Clinic\u27s Process to Increase Preventative Health Screenings

Performing health screenings on patients is a potential way to prevent or even identify health issues that may have not otherwise been apparent. In recognition of the importance of this matter, this CNL aims to improve and increase the percentage rate of depression and cervical cancer screenings by addressing barriers that have hindered staff from performing these health screenings. This CNL project took place at a health clinic located in the marginalized community of San Francisco. The health clinic’s primary focus is to foster care to the underserved population—homeless, uninsured, LGBTQ, people of color—and provide them with qualitative patient care. According to the organization’s policy, these preventative health screenings must be performed on every patient of the clinic. However, because this is a small clinic with limited staff and resources, and due to the taxing demands of each of the staff members, they lack efficient performance in EHR consistency and the process of health screening expectations. The generation of baseline data shows that in the last year 51% of patients were screened for depression and 14% of patients were screened for cervical cancer. Therefore, a goal of this project is to ensure staff follows a consistent screening process each time a patient is seen in the health clinic. Education awareness of the problem and visual cueing—a Reference List, Visual Signage, and an EHR Flowchart List—were used to prompt and remind staff that health screenings should be performed. This method was implemented over a three-week period and as a result, preliminary data showed that 54% of patients were screened for depression and 22% were screened for cervical cancer. This is indicative that after post- implementation, there has been a slight increase of screenings within the three-week study due to effective strategies that were utilized to reduce barriers and promote staff compliance and efficiency