Implementation and evaluation of an electronic health record-integrated app for postpartum monitoring of hypertensive disorders of pregnancy using patient-contributed data collection
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PROVIDER: S-EPMC10646567 | biostudies-literature | 2023 Nov
REPOSITORIES: biostudies-literature
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Project description:BackgroundClinical decision support (CDS) tools in electronic health records (EHRs) are often used as core strategies to support quality improvement programs in the clinical setting. Monitoring the impact (intended and unintended) of these tools is crucial for program evaluation and adaptation. Existing approaches for monitoring typically rely on health care providers' self-reports or direct observation of clinical workflows, which require substantial data collection efforts and are prone to reporting bias.ObjectiveThis study aims to develop a novel monitoring method leveraging EHR activity data and demonstrate its use in monitoring the CDS tools implemented by a tobacco cessation program sponsored by the National Cancer Institute's Cancer Center Cessation Initiative (C3I).MethodsWe developed EHR-based metrics to monitor the implementation of two CDS tools: (1) a screening alert reminding clinic staff to complete the smoking assessment and (2) a support alert prompting health care providers to discuss support and treatment options, including referral to a cessation clinic. Using EHR activity data, we measured the completion (encounter-level alert completion rate) and burden (the number of times an alert was fired before completion and time spent handling the alert) of the CDS tools. We report metrics tracked for 12 months post implementation, comparing 7 cancer clinics (2 clinics implemented the screening alert and 5 implemented both alerts) within a C3I center, and identify areas to improve alert design and adoption.ResultsThe screening alert fired in 5121 encounters during the 12 months post implementation. The encounter-level alert completion rate (clinic staff acknowledged completion of screening in EHR: 0.55; clinic staff completed EHR documentation of screening results: 0.32) remained stable over time but varied considerably across clinics. The support alert fired in 1074 encounters during the 12 months. Providers acted upon (ie, not postponed) the support alert in 87.3% (n=938) of encounters, identified a patient ready to quit in 12% (n=129) of encounters, and ordered a referral to the cessation clinic in 2% (n=22) of encounters. With respect to alert burden, on average, both alerts fired over 2 times (screening alert: 2.7; support alert: 2.1) before completion; time spent postponing the screening alert was similar to completing (52 vs 53 seconds) the alert, and time spent postponing the support alert was more than completing (67 vs 50 seconds) the alert per encounter. These findings inform four areas where the alert design and use can be improved: (1) improving alert adoption and completion through local adaptation, (2) improving support alert efficacy by additional strategies including training in provider-patient communication, (3) improving the accuracy of tracking for alert completion, and (4) balancing alert efficacy with the burden.ConclusionsEHR activity metrics were able to monitor the success and burden of tobacco cessation alerts, allowing for a more nuanced understanding of potential trade-offs associated with alert implementation. These metrics can be used to guide implementation adaptation and are scalable across diverse settings.
| S-EPMC10020903 | biostudies-literature
Project description:ObjectivesHypertensive disorders of pregnancy (HDP) affect one in ten pregnancies and often persist postpartum when complications can occur. We aimed to determine the effectiveness and safety of pharmacological interventions, other interventions and different care models for postpartum hypertension management.DesignA systematic review was undertaken. Nine electronic databases, including Medline, were searched from inception to 16 March 2017. After duplicate removal, 4561 records were screened. Two authors independently selected studies, extracted study characteristics and data, and assessed methodological quality.SettingRandomised controlled trials, case-control studies and cohort studies from any country and healthcare setting.ParticipantsPostnatal women with HDP.InterventionsTherapeutic intervention for management of hypertension, compared with another intervention, placebo or no intervention.Primary and secondary outcome measuresOutcome data were collected for maternal mortality and severe morbidity; systolic, diastolic and mean arterial blood pressure (BP) control; and safety data. Secondary outcome data collected included the length of postnatal hospital stay and laboratory values.Results39 studies were included (n=2901). Results were heterogeneous in terms of intervention, comparison and outcome requiring a narrative approach. There were insufficient data to recommend any single pharmacological intervention. 18 studies reported calcium-channel blockers, vasodilators and beta-blockers lowered BP postpartum. 12 of these reported safety data. Limited data existed regarding management in the weeks following hospital discharge. Neither loop diuretics (three studies) nor corticosteroids (one study) produced clinical benefit. Uterine curettage significantly reduced BP over the first 48 hours postpartum (range 6-13 mm Hg) compared with standard care (eight studies), with safety data only reported by four of eight studies.ConclusionThere was insufficient evidence to recommend a particular BP threshold, agent or model of care, but three classes of antihypertensive appeared variably effective. Further comparative research, including robust safety data, is required. Curettage reduced BP, but without adequate reporting of harms, so it cannot currently be recommended.
| S-EPMC5719299 | biostudies-literature
Project description:BackgroundParents of children newly diagnosed with cancer are confronted with multiple stressors that place them at risk for significant psychological distress. One strategy that has been shown to help reduce uncertainty is the provision of basic information; however, families of newly diagnosed cancer patients are often bombarded with educational material. Technology has the potential to help families manage their informational needs and move towards normalization.ObjectiveThe aim of this study was to create a mobile app that pulls together data from both the electronic health record (EHR) and vetted external information resources to provide tailored information to parents of newly diagnosed children as one method to reduce the uncertainty around their child's illness. This app was developed to be used by families in a National Institutes of Health (NIH)-funded randomized controlled trial (RCT) aimed at decreasing uncertainty and the subsequent psychological distress.MethodsA 2-phase qualitative study was conducted to elicit the features and content of the mobile app based on the needs and experience of parents of children newly diagnosed with cancer and their providers. Example functions include the ability to view laboratory results, look up appointments, and to access educational material. Educational material was obtained from databases maintained by the National Cancer Institute (NCI) as well as from groups like the Children's Oncology Group (COG) and care teams within Cincinnati Children's Hospital Medical Center (CCHMC). The use of EHR-based Web services was explored to allow data like laboratory results to be retrieved in real-time.ResultsThe ethnographic design process resulted in a framework that divided the content of the mobile app into the following 4 sections: (1) information about the patient's current treatment and other data from the EHR; (2) educational background material; (3) a calendar to view upcoming appointments at their medical center; and (4) a section where participants in the RCT document the study data. Integration with the NCI databases was straightforward; however, accessing the EHR Web services posed a challenge, though the roadblocks were not technical in nature. The lack of a formal, end-to-end institutional process for requesting Web service access and a mechanism to shepherd the request through all stages of implementation proved to be the biggest barrier.ConclusionsWe successfully deployed a mobile app with a custom user interface that can integrate with the EHR to retrieve laboratory results and appointment information using vendor-provided Web services. Developers should expect to face hurdles when integrating with the EHR, but many of them can be addressed with frequent communication and thorough documentation. Executive sponsorship is also a key factor for success.Trial registrationClinicalTrials.gov NCT02505165; https://clinicaltrials.gov/ct2/show/NCT02505165 (Archived by WebCite at http://www.Webcitation.org/6r9ZSUgoT).
| S-EPMC5506330 | biostudies-literature
Project description:There are over 1 million transgender people living in the United States, and 33% report negative experiences with a healthcare provider, many of which are connected to data representation in electronic health records (EHRs). We present recommendations and common pitfalls involving sex- and gender-related data collection in EHRs. Our recommendations leverage the needs of patients, medical providers, and researchers to optimize both individual patient experiences and the efficacy and reproducibility of EHR population-based studies. We also briefly discuss adequate additions to the EHR considering name and pronoun usage. We add the disclaimer that these questions are more complex than commonly assumed. We conclude that collaborations between local transgender and gender-diverse persons and medical providers as well as open inclusion of transgender and gender-diverse individuals on terminology and standards boards is crucial to shifting the paradigm in transgender and gender-diverse health.
| S-EPMC8757312 | biostudies-literature
Project description:BackgroundElectronic Medical Records (EMRs) are one of a range of digital health solutions that are key enablers of the data revolution transforming the health sector. They offer a wide range of benefits to health professionals, patients, researchers and other key stakeholders. However, effective implementation has proved challenging.MethodsA qualitative methodology was used in the study. Interviews were conducted with 12 clinical and administrative staff of a cancer centre at one-month pre-launch and eight clinical and administrative staff at 12-months post-launch of an EMR. Data from the interviews was collected via audio recording. Audio recordings were transcribed, de-identified and analysed to identify staff experiences with the EMR.ResultsData from the pre-implementation interviews were grouped into four categories: 1) Awareness and understanding of EMR; 2) Engagement in launch process; 3) Standardisation and completeness of data; 4) Effect on workload. Data from the post-launch interviews were grouped into six categories: 1) Standardisation and completeness of data; 2) Effect on workload; 3) Feature completeness and functionality; 4) Interaction with technical support; 5) Learning curve; 6) Buy-in from staff. Two categories: Standardisation and completeness of data and effect on workload were common across pre and post-implementation interviews.ConclusionFindings from this study contribute new knowledge on barriers and enablers to the implementation of EMRs in complex clinical settings. Barriers to successful implementation include lack of technical support once the EMR has launched, health professional perception the EMR increases workload, and the learning curve for staff adequately familiarize themselves with using the EMR.
| S-EPMC7789279 | biostudies-literature
Project description:Hypertensive disorders of pregnancy are a leading cause of pregnancy-related morbidity and mortality. The primary objective of this study was to compare the frequency of documentation of postpartum blood pressure through remote blood pressure monitoring with text-message delivered reminders versus office-based follow-up 7-10 days postpartum. The secondary objective was to examine barriers and facilitators of both care strategies from the perspectives of individuals who experienced a hypertensive disorder of pregnancy. We conducted a randomized controlled trial at a tertiary care academic medical center in the southeastern US with 100 postpartum individuals (50 per arm) from 2018 to 2019. Among 100 trial participants, blood pressure follow-up within 7-10 days postpartum was higher albeit not statistically significant between postpartum individuals randomized to the remote assessment intervention versus office-based standard care (absolute risk difference 18.0%, 95% CI -0.1 to 36.1%, p = 0.06). Patient-reported facilitators for remote blood pressure monitoring were maternal convenience, clarity of instructions, and reassurance from the health assessments. These positive aspects occurred alongside barriers, which included constraints due to newborn needs and the realities of daily postpartum life.
| S-EPMC11311182 | biostudies-literature
Project description:BackgroundElectronic health record (EHR) systems have undergone substantial evolution over the past 25 years, transitioning from rudimentary digital repositories to sophisticated tools that are integral to modern health care delivery. These systems have the potential to increase efficiency and improve patient care. However, for these systems to reach their potential, we need to understand how the process of EHR implementation works.ObjectiveThis scoping review aimed to examine the implementation process of EHRs from 1999 to 2024 and to articulate process-focused recommendations for future EHR implementations that build on this history of EHR research.MethodsWe conducted a scoping literature review following a systematic methodological framework. A total of 5 databases were selected from the disciplines of medicine and business: EBSCO, PubMed, Embase, IEEE Explore, and Scopus. The search included studies published from 1999 to 2024 that addressed the process of implementing an EHR. Keywords included "EHR," "EHRS," "Electronic Health Record*," "EMR," "EMRS," "Electronic Medical Record*," "implemen*," and "process." The findings were reported in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist. The selected literature was thematically coded using NVivo qualitative analysis software, with the results reported qualitatively.ResultsThis review included 90 studies that described the process of EHR implementation in different settings. The studies identified key elements, such as the role of the government and vendors, the importance of communication and relationships, the provision of training and support, and the implementation approach and cost. Four process-related categories emerged from these results: compliance processes, collaboration processes, competence-development processes, and process costs.ConclusionsAlthough EHRs hold immense promise in improving patient care, enhancing research capabilities, and optimizing health care efficiency, there is a pressing need to examine the actual implementation process to understand how to approach implementation. Our findings offer 7 process-focused recommendations for EHR implementation formed from analysis of the selected literature.
| S-EPMC11914847 | biostudies-literature
Project description:ObjectiveTo examine the financial impact of electronic health record (EHR) implementation on ambulatory practices.MethodsWe tracked the practice productivity (ie, number of patient visits) and reimbursement of 30 ambulatory practices for 2 years after EHR implementation and compared each practice to their pre-EHR implementation baseline.ResultsReimbursements significantly increased after EHR implementation even though practice productivity (ie, the number of patient visits) decreased over the 2-year observation period. We saw no evidence of upcoding or increased reimbursement rates to explain the increased revenues. Instead, they were associated with an increase in ancillary office procedures (eg, drawing blood, immunizations, wound care, ultrasounds).DiscussionThe bottom line result-that EHR implementation is associated with increased revenues-is reassuring and offers a basis for further EHR investment. While the productivity losses are consistent with field reports, they also reflect a type of efficiency-the practices are receiving more reimbursement for fewer seeing patients. For the practices still seeing fewer patients after 2 years, the solution likely involves advancing their EHR functionality to include analytics. Although they may still see fewer patients, with EHR analytics, they can focus on seeing the right patients.ConclusionsPractice reimbursements increased after EHR implementation, but there was a long-term decrease in the number of patient visits seen in this ambulatory practice context.
| S-EPMC11749187 | biostudies-literature
Project description:ObjectivePhenotyping algorithms applied to electronic health record (EHR) data enable investigators to identify large cohorts for clinical and genomic research. Algorithm development is often iterative, depends on fallible investigator intuition, and is time- and labor-intensive. We developed and evaluated 4 types of phenotyping algorithms and categories of EHR information to identify hypertensive individuals and controls and provide a portable module for implementation at other sites.Materials and methodsWe reviewed the EHRs of 631 individuals followed at Vanderbilt for hypertension status. We developed features and phenotyping algorithms of increasing complexity. Input categories included International Classification of Diseases, Ninth Revision (ICD9) codes, medications, vital signs, narrative-text search results, and Unified Medical Language System (UMLS) concepts extracted using natural language processing (NLP). We developed a module and tested portability by replicating 10 of the best-performing algorithms at the Marshfield Clinic.ResultsRandom forests using billing codes, medications, vitals, and concepts had the best performance with a median area under the receiver operator characteristic curve (AUC) of 0.976. Normalized sums of all 4 categories also performed well (0.959 AUC). The best non-NLP algorithm combined normalized ICD9 codes, medications, and blood pressure readings with a median AUC of 0.948. Blood pressure cutoffs or ICD9 code counts alone had AUCs of 0.854 and 0.908, respectively. Marshfield Clinic results were similar.ConclusionThis work shows that billing codes or blood pressure readings alone yield good hypertension classification performance. However, even simple combinations of input categories improve performance. The most complex algorithms classified hypertension with excellent recall and precision.
| S-EPMC5201185 | biostudies-literature
Project description:AIMS:The cumulative effect of gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP) on postpartum cardio-metabolic diseases is equivocal. We aimed to assess the associations of GDM and HDP's individual and synergic contribution to risks of postpartum cardio-metabolic diseases (metabolic syndrome (MetS), abnormal glucose metabolism and hypertension (HTN)). METHODS:Of participants from a Singapore birth cohort, 276 mothers attending the 5-year postpartum visit were included in this study. During this visit, we collected mothers' history of GDM and HDP in all live births in a chronicle sequence and assessed the cardio-metabolic risks based on blood pressure, anthropometry and a panel of serum biomarkers. We diagnosed MetS, abnormal glucose metabolism and HTN according to Adult Treatment Panel III 2000 and World Health Organization guidelines. RESULTS:Of 276 mothers, 157 (56.9%) had histories of GDM while 23 (8.3%) had histories of HDP. After full adjustment, we found associations of GDM episodes with postpartum abnormal glucose metabolism (single episode: relative risk (RR) 2.9 (95% CI: 1.7, 4.8); recurrent episodes (≥2): RR = 3.8 (2.1-6.8)). Also, we found association between histories of HDP and HTN (RR = 3.6 (1.5, 8.6)). Having either (RR 2.6 (1.7-3.9)) or both gestational complications (RR 2.7 (1.6-4.9)) was associated with similar risk of postpartum cardio-metabolic disease. CONCLUSIONS:Mothers with GDM or HDP had a threefold increased risk of postpartum abnormal glucose metabolism or HTN, respectively. Having both GDM and HDP during past pregnancies was not associated with additional risk of postpartum cardio-metabolic diseases beyond that associated with either complication alone.
| S-EPMC5834770 | biostudies-literature