Validation of an electronic trigger to measure missed diagnosis of stroke in emergency departments

ObjectiveDiagnostic errors are major contributors to preventable patient harm. We validated the use of an electronic health record (EHR)-based trigger (e-trigger) to measure missed opportunities in stroke diagnosis in emergency departments (EDs).MethodsUsing two frameworks, the Safer Dx Trigger Tools Framework and the Symptom-disease Pair Analysis of Diagnostic Error Framework, we applied a symptom–disease pair-based e-trigger to identify patients hospitalized for stroke who, in the preceding 30 days, were discharged from the ED with benign headache or dizziness diagnoses. The algorithm was applied to Veteran Affairs National Corporate Data Warehouse on patients seen between 1/1/2016 and 12/31/2017. Trained reviewers evaluated medical records for presence/absence of missed opportunities in stroke diagnosis and stroke-related red-flags, risk factors, neurological examination, and clinical interventions. Reviewers also estimated quality of clinical documentation at the index ED visit.ResultsWe applied the e-trigger to 7,752,326 unique patients and identified 46,931 stroke-related admissions, of which 398 records were flagged as trigger-positive and reviewed. Of these, 124 had missed opportunities (positive predictive value for “missed” = 31.2%), 93 (23.4%) had no missed opportunity (non-missed), 162 (40.7%) were miscoded, and 19 (4.7%) were inconclusive. Reviewer agreement was high (87.3%, Cohen’s kappa = 0.81). Compared to the non-missed group, the missed group had more stroke risk factors (mean 3.2 vs 2.6), red flags (mean 0.5 vs 0.2), and a higher rate of inadequate documentation (66.9% vs 28.0%).ConclusionIn a large national EHR repository, a symptom–disease pair-based e-trigger identified missed diagnoses of stroke with a modest positive predictive value, underscoring the need for chart review validation procedures to identify diagnostic errors in large data sets.     

消化性溃疡患者Cag A蛋白及Gas的水平变化特点及诊断学价值分析

目的:探究消化性溃疡患者Cag A蛋白及Gas的水平变化特点,评价两种因子对于消化性溃疡的诊断学价值。方法:选取2016年1月-2017年6月我院消化科收治的128例良性消化道疾病患者为观察组,检测各受试者血清Cag A蛋白表达阳性率及血清Gas水平均值,并以大于所有受试者血清Gas浓度中位数为阳性限,后经胃镜确诊128例患者中胃溃疡35例,十二指肠溃疡45例,慢性胃炎48例,统计各类病变患者Cag A蛋白表达阳性率及血清Gas阳性率,分析Cag A蛋白阳性表达和血清Gas阳性表达两个指标对消化性溃疡诊断的敏感性及特异性。结果:在128例消化性溃疡患者中,94例血清Cag A检测呈阳性,敏感性为73.43%（94/128）,在健康体检者中,104例血清Cag A检测呈阴性,特异性为81.28%（104/128）,消化性溃疡患者血清Gas浓度均值为（56.89±9.24）ng/L,显著高于对照组（40.68±8.27）ng/L。选取所有受试者血清Gas浓度中位数46.50 ng/L 为阳性,对消化性溃疡诊断的敏感性为79.68%（102/128）,特异性为83.59%。结论:消化性溃疡患者血清Cag A阳性表达率和Gas水平均显著高于健康人群,两项指标在消化性溃疡诊断中均具有较高的敏感性和特异性。     

纤维支气管镜针吸术对肺癌的诊断价值

目的 观察经纤维支气管镜针吸术对肺癌的诊断价值。方法 对２２例肺癌患者采用经纤维支气管镜吸活检，刷检，钳夹活检进行分析。结果 针吸活检，刷检，钳夹活检阳性率分别为７２．７２％，６８．１８％，６３．６３％，针吸活检结合刷检阳性率８６．３６％，针吸活检结合刷检较单纯钳夹活检对诊断肺癌的阳性率存在显著性差异，结论经纤维支气管镜针吸活检结合刷检方法简单，安全，并发症少，在不易钳夹活检的肺癌诊断上有一定价值     

心理访谈对改善脑卒中患者抑郁程度的效果评价

目的建立医生与患者的谈话制度,要求对抑郁患者进行有针对性的心理沟通与健康教育等访谈,以期改善抑郁程度。方法采用24项HAMD进行筛选,对60例具有抑郁的脑卒中患者分别于干预前后进行量表测定,以观察效果。结果患者抑郁程度有明显改善,经χ2检验P〈0.005。结论心理访谈对改善脑卒中患者抑郁情绪,提高生活质量是行之有效的方法,从而保证了治疗顺利进行,对脑卒中的治疗起了积极的促进作用。     

Evaluation of electronic health record-integrated digital health tools to engage hospitalized patients in discharge preparation

ObjectiveTo evaluate the effect of electronic health record (EHR)-integrated digital health tools comprised of a checklist and video on transitions-of-care outcomes for patients preparing for discharge.Materials and MethodsEnglish-speaking, general medicine patients (>18 years) hospitalized at least 24 hours at an academic medical center in Boston, MA were enrolled before and after implementation. A structured checklist and video were administered on a mobile device via a patient portal or web-based survey at least 24 hours prior to anticipated discharge. Checklist responses were available for clinicians to review in real time via an EHR-integrated safety dashboard. The primary outcome was patient activation at discharge assessed by patient activation (PAM)-13. Secondary outcomes included postdischarge patient activation, hospital operational metrics, healthcare resource utilization assessed by 30-day follow-up calls and administrative data and change in patient activation from discharge to 30 days postdischarge.ResultsOf 673 patients approached, 484 (71.9%) enrolled. The proportion of activated patients (PAM level 3 or 4) at discharge was nonsignificantly higher for the 234 postimplementation compared with the 245 preimplementation participants (59.8% vs 56.7%, adjusted OR 1.23 [0.38, 3.96], P = .73). Postimplementation participants reported 3.75 (3.02) concerns via the checklist. Mean length of stay was significantly higher for postimplementation compared with preimplementation participants (10.13 vs 6.21, P < .01). While there was no effect on postdischarge outcomes, there was a nonsignificant decrease in change in patient activation within participants from pre- to postimplementation (adjusted difference-in-difference of −16.1% (9.6), P = .09).ConclusionsEHR-integrated digital health tools to prepare patients for discharge did not significantly increase patient activation and was associated with a longer length of stay. While issues uncovered by the checklist may have encouraged patients to inquire about their discharge preparedness, other factors associated with patient activation and length of stay may explain our observations. We offer insights for using PAM-13 in context of real-world health-IT implementations.Trial RegistrationNIH US National Library of Medicine, {"type":"clinical-trial","attrs":{"text":"NCT03116074","term_id":"NCT03116074"}}NCT03116074, clinicaltrials.gov     

Development of a tool within the electronic medical record to facilitate medication reconciliation after hospital discharge

Serious medication errors occur commonly in the period after hospital discharge. Medication reconciliation in the postdischarge ambulatory setting may be one way to reduce the frequency of these errors. The authors describe the design and implementation of a novel tool built into an ambulatory electronic medical record (EMR) to facilitate postdischarge medication reconciliation. The tool compares the preadmission medication list within the ambulatory EMR to the hospital discharge medication list, highlights all changes, and allows the EMR medication list to be easily updated. As might be expected for a novel tool intended for use in a minority of visits, use of the tool was low at first: 20% of applicable patient visits within 30 days of discharge. Clinician outreach, education, and a pop-up reminder succeeded in increasing use to 41% of applicable visits. Review of feedback identified several usability issues that will inform subsequent versions of the tool and provide generalizable lessons for how best to design medication reconciliation tools for this setting.     

肺部X线阴影与纤维支气管镜检查的对比分析

目的　研究X线检查与纤维支气管镜检查在胸部发现阴影时诊断的符合情况。方法　对 2 2 3例经X线、CT检查发现肺部阴影、同时做纤维支气管镜及病理检查确诊的患者作回顾性分析。结果　经纤维支气管镜检查确定诊断 :炎症 93例 (41.7% ) ,结核 5 3例 (2 3.8% ) ,肿瘤 6 6例 (2 9.6 % )及其他 11例 (4.9% )。胸部X线检查与纤维支气管镜检查符合率 76 .2 %。结论　纤维支气管镜检查能补充胸部X线检查的不足     

Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial

Objective

To determine the effects of a personal health record (PHR)-linked medications module on medication accuracy and safety.

Design

From September 2005 to March 2007, we conducted an on-treatment sub-study within a cluster-randomized trial involving 11 primary care practices that used the same PHR. Intervention practices received access to a medications module prompting patients to review their documented medications and identify discrepancies, generating ‘eJournals’ that enabled rapid updating of medication lists during subsequent clinical visits.

Measurements

A sample of 267 patients who submitted medications eJournals was contacted by phone 3 weeks after an eligible visit and compared with a matched sample of 274 patients in control practices that received a different PHR-linked intervention. Two blinded physician adjudicators determined unexplained discrepancies between documented and patient-reported medication regimens. The primary outcome was proportion of medications per patient with unexplained discrepancies.

Results

Among 121 046 patients in eligible practices, 3979 participated in the main trial and 541 participated in the sub-study. The proportion of medications per patient with unexplained discrepancies was 42% in the intervention arm and 51% in the control arm (adjusted OR 0.71, 95% CI 0.54 to 0.94, p=0.01). The number of unexplained discrepancies per patient with potential for severe harm was 0.03 in the intervention arm and 0.08 in the control arm (adjusted RR 0.31, 95% CI 0.10 to 0.92, p=0.04).

Conclusions

When used, concordance between documented and patient-reported medication regimens and reduction in potentially harmful medication discrepancies can be improved with a PHR medication review tool linked to the provider''s medical record.

Trial registration number

This study was registered at ClinicalTrials.gov ({"type":"clinical-trial","attrs":{"text":"NCT00251875","term_id":"NCT00251875"}}NCT00251875).     

Brief communication: Patient–provider communication and trust in relation to use of an online patient portal among diabetes patients: The Diabetes and Aging Study

Patient–provider relationships influence diabetes care; less is known about their impact on online patient portal use. Diabetes patients rated provider communication and trust. In this study, we linked responses to electronic medical record data on being a registered portal user and using secure messaging (SM). We specified regression models to evaluate main effects on portal use, and subgroup analyses by race/ethnicity and age. 52% of subjects were registered users; among those, 36% used SM. Those reporting greater trust were more likely to be registered users (relative  risk (RR)=1.14) or SM users (RR=1.29). In subgroup analyses, increased trust was associated with being a registered user among white, Latino, and older patients, as well as SM use among white patients. Better communication ratings were also related to being a registered user among older patients. Since increased trust and communication were associated with portal use within subgroups, this suggests that patient-provider relationships encourage portal engagement.     

医学生对标准化病人应用于临床医学专业执业医师技能考核的认知及满意度评价研究

目的 了解医学生对标准化病人（SP）应用于临床医学专业执业医师技能考核的认知及满意度评价情况,为加强医学人才培养、推动安徽省医学教育改革提供参考依据。方法 2021年5月以问卷调查的方式收集546名参加安徽省某高校2021年临床执业医师技能考核的学生对SP认知情况及满意度评价情况,同时开展临床执业医师技能考核,收集学生考核通过情况。采用χ2检验对SP应用于临床技能考核的认知情况及满意度评价情况进行分析。结果 546名医学生的临床执业医师技能考核合格率为84.80%。调查对象知晓SP教学或考核的比例为88.64%,接受过SP教学或考核的比例为17.77%。调查对象对SP临床技能考核的满意率为89.38%,五个层面的满意率从高到低依次为剧本内容（94.32%）、场所设施（93.77%）、时间安排（89.93%）、试题难度（88.64%）、角色表现（85.35%）。不同学制、不同SP临床技能考核通过情况的调查对象在SP应用于临床专业执业医师技能考核认知情况及满意度评价方面存在差异（P<0.05）。结论 SP临床技能考核的应用情况和满意度评价情况需进一步提升,建议卫生教育主管部门明确使用...     

Evaluation of an Android-based mHealth system for population surveillance in developing countries

Objective

In parts of the developing world traditionally modeled healthcare systems do not adequately meet the needs of the populace. This can be due to imbalances in both supply and demand—there may be a lack of sufficient healthcare and the population most at need may be unable or unwilling to take advantage of it. Home-based care has emerged as a possible mechanism to bring healthcare to the populace in a cost-effective, useful manner. This study describes the development, implementation, and evaluation of a mobile device-based system to support such services.

Materials and Methods

Mobile phones were utilized and a structured survey was implemented to be administered by community health workers using Open Data Kit. This system was used to support screening efforts for a population of two million persons in western Kenya.

Results

Users of the system felt it was easy to use and facilitated their work. The system was also more cost effective than pen and paper alternatives.

Discussion

This implementation is one of the largest applications of a system utilizing handheld devices for performing clinical care during home visits in a resource-constrained environment. Because the data were immediately available electronically, initial reports could be performed and important trends in data could thus be detected. This allowed adjustments to the programme to be made sooner than might have otherwise been possible.

Conclusion

A viable, cost-effective solution at scale has been developed and implemented for collecting electronic data during household visits in a resource-constrained setting.     

Validation of a common data model for active safety surveillance research

OBJECTIVE: Systematic analysis of observational medical databases for active safety surveillance is hindered by the variation in data models and coding systems. Data analysts often find robust clinical data models difficult to understand and ill suited to support their analytic approaches. Further, some models do not facilitate the computations required for systematic analysis across many interventions and outcomes for large datasets. Translating the data from these idiosyncratic data models to a common data model (CDM) could facilitate both the analysts' understanding and the suitability for large-scale systematic analysis. In addition to facilitating analysis, a suitable CDM has to faithfully represent the source observational database. Before beginning to use the Observational Medical Outcomes Partnership (OMOP) CDM and a related dictionary of standardized terminologies for a study of large-scale systematic active safety surveillance, the authors validated the model's suitability for this use by example. VALIDATION BY EXAMPLE: To validate the OMOP CDM, the model was instantiated into a relational database, data from 10 different observational healthcare databases were loaded into separate instances, a comprehensive array of analytic methods that operate on the data model was created, and these methods were executed against the databases to measure performance. CONCLUSION: There was acceptable representation of the data from 10 observational databases in the OMOP CDM using the standardized terminologies selected, and a range of analytic methods was developed and executed with sufficient performance to be useful for active safety surveillance.