The Building Blocks of Interoperability. A Multisite Analysis of Patient Demographic Attributes Available for Matching.

BackgroundPatient matching is a key barrier to achieving interoperability. Patient demographic elements must be consistently collected over time and region to be valuable elements for patient matching.ObjectivesWe sought to determine what patient demographic attributes are collected at multiple institutions in the United States and see how their availability changes over time and across clinical sites.MethodsWe compiled a list of 36 demographic elements that stakeholders previously identified as essential patient demographic attributes that should be collected for the purpose of linking patient records. We studied a convenience sample of 9 health care systems from geographically distinct sites around the country. We identified changes in the availability of individual patient demographic attributes over time and across clinical sites.ResultsSeveral attributes were consistently available over the study period (2005-2014) including last name (99.96%), first name (99.95%), date of birth (98.82%), gender/sex (99.73%), postal code (94.71%), and full street address (94.65%). Other attributes changed significantly from 2005-2014: Social security number (SSN) availability declined from 83.3% to 50.44% (p<0.0001). Email address availability increased from 8.94% up to 54% availability (p<0.0001). Work phone number increased from 20.61% to 52.33% (p<0.0001).ConclusionsOverall, first name, last name, date of birth, gender/sex and address were widely collected across institutional sites and over time. Availability of emerging attributes such as email and phone numbers are increasing while SSN use is declining. Understanding the relative availability of patient attributes can inform strategies for optimal matching in healthcare

Use of a Computerized C-Reactive Protein (CRP) Based Sepsis Evaluation in Very Low Birth Weight (VLBW) Infants: A Five-Year Experience

<div><p>Background</p><p>Serial C-reactive protein (CRP) values may be useful for decision-making regarding duration of antibiotics in neonates. However, established standard of practice for its use in preterm very low birth weight (<1500 g, VLBW) infants are lacking.</p><p>Objective</p><p>Evaluate compliance with a CRP-guided computerized decision support (CDS) algorithm and compare characteristics and outcomes of compliant versus non-compliant cases. Measure correlation between CRPs and white blood count (WBC) indices.</p><p>Methods</p><p>We examined 3 populations: 1) all preterm VLBW infants born at Vanderbilt 2006–2011 – we assessed provider compliance with CDS algorithm and measured relevant outcomes; 2) all patients with positive blood culture results admitted to the Vanderbilt NICU 2006–2012 – we tested the correlation between CRP and WBC results within 7 days of blood culture phlebotomy; 3) 1,000 randomly selected patients out of the 7,062 patients admitted to the NICU 2006–2012 – we correlated time-associated CRP values and absolute neutrophil counts.</p><p>Results</p><p>Of 636 VLBW infants in cohort 1), 569 (89%) received empiric antibiotics for suspected early-onset sepsis. In 409 infants (72%) the CDS algorithm was followed; antibiotics were discontinued ≤48 hours in 311 (55%) with normal serial CRPs and continued in 98 (17%) with positive CRPs, resulting in significant reduction in antibiotic exposure (p<0.001) without increase in complications or subsequent infections. One hundred sixty (28%) were considered non-compliant because antibiotics were continued beyond 48 hours despite negative serial CRPs and blood cultures. Serial CRPs remained negative in 38 (12%) of 308 blood culture-positive infants from cohort 2, but only 4 patients had clinically probable sepsis with single organisms and no immunodeficiency besides extreme prematurity. Leukopenia of any cell type was not linked with CRPs in cohorts 2 and 3.</p><p>Conclusions</p><p>CDS/CRP-guided antibiotic use is safe and effective in culture-negative VLBW infants. CRP results are not affected by low WBC indices.</p></div

Patient demographics by CRP-protocol compliance status.¹

1<p>Compliance with the CRP-protocol in the setting of negative blood cultures was defined as (1) antibiotics were discontinued ≤48 hours after 2 consecutive negative CRP results, or continued if at least one positive CRP was present [“CRP-protocol compliant” (Comp)], and (2) antibiotics were continued >48 hours despite negative serial CRP results [“CRP-protocol non-compliant” (Non-Comp)].</p>2<p>Pair-wise comparison between Comp and Non-Comp group.</p>3<p>Median (lower quartile; upper quartile).</p>4<p>Wilcoxon test.</p>5<p>Pearson test.</p>6<p>C =  Caucasian, AA  =  African American, H =  Hispanic, O =  Other, U =  Unknown.</p>7<p>Absolute neutrophil count at time of initial sepsis evaluation.</p>8<p><2,500/µL.</p>9<p>Absolute neutrophil count at 48 hours.</p

Number of cases (N) with confirmed positive blood cultures and low WBC indices with positive (>10 mg/L) CRP values versus negative (<10 mg/L) serial CRP results.¹

1<p> =  Only cases with a full set of reported WBC and differential were analyzed.</p>2<p> =  CONS  =  coagulase-negative <i>Staphylococcus</i>.</p>3<p> =  Total serial CRP pos. N = 43; total serial CRP neg. N = 17.</p>4<p> =  Total serial CRP pos. N = 54; total serial CRP neg. N = 16.</p

Organisms isolated from positive blood cultures in patients with confirmed infections (N = 38) and CRP persistently <10 mg/L.

<p>Organisms isolated from positive blood cultures in patients with confirmed infections (N = 38) and CRP persistently <10 mg/L.</p

Reasons stated by clinical providers in the clinical decision support (CDS) module for continued antibiotic therapy despite negative serial CRP values.

1<p>Providers were able to state more than one reason.</p>2<p>Included preterm premature rupture of membranes (PPROM), Group B <i>streptococcus</i> (GBS) status, chorioamnionitis, fever.</p>3<p>Included concerns for respiratory and gastrointestinal pathology.</p

Outcomes (%) by CRP-protocol compliance status.¹

1<p>Compliance with the CRP-protocol in the setting of negative blood cultures was defined as (1) antibiotics were discontinued ≤48 hours after 2 consecutive negative CRP results or continued after at least one positive CRP value [“CRP-protocol compliant” (Comp)], and (2) antibiotics were continued >48 hours despite negative serial CRP results [“CRP-protocol non-compliant” (Non-Comp)].</p>2<p>Pearson test.</p>3<p>Defined as supplemental oxygen requirement ≥36 weeks postconceptional age.</p>4<p>CONS  =  Coagulase-negative <i>Staphylococcus</i>.</p

Screenshot decision support to stop antibiotics.

<p>The CRP protocol's recommendation on antibiotic use was based on repeat CRP and WBC results drawn 48 hours following initial evaluation. In cases with two consecutively negative CRP results (CRP <10 mg/L), this discontinuation screen appeared, allowing the provider to choose to stop antibiotics. If the provider chose to continue antibiotics despite negative CRP results, they were prompted to provide reasoning for doing so. No complete white blood count (CBC) data is depicted in this screenshot, because a “test” patient had to be generated to produce this figure.</p