Do You Know What Your Scribe Did Last Spring? The Impact of COVID-19 on Medical Scribe Workflow

Objective  To understand the impact of the shift to virtual medicine induced by coronavirus disease 2019 (COVID-19) has had on the workflow of medical scribes. Design  This is a prospective observational survey-based study. Setting  This study was conducted at academic medical center in the United States. Participants  Seventy-four scribes working in ambulatory practices within an academic medical center. Interventions  All medical scribes received a survey assessing their workflow since beginning of COVID-19 restrictions. Primary and Secondary Outcomes  To assess the current workflow of medical scribes since transition to virtual care. Secondary outcomes are to assess the equipment used and location of their new workflow. Results  Fifty-seven scribes completed the survey. Overall 42% of scribes have transitioned to remote scribing with 97% serving as remote scribes for remote visits. This workflow is conducted at home and with personal equipment. Of those not working as scribes, 46% serve in preclinic support, with a wide range of EHR-related activities being reported. The remaining scribes have been either redeployed or furloughed. Conclusion  The rapid transition to virtual care brought about by COVID-19 has resulted in a dramatic shift in scribe workflow with the adoption of a previously unreported workflow of remote scribing for virtual care. Additional work is now needed to ensure these new workflows are safe and effective and that scribes are trained to work in this new paradigm.     

Ambulatory Clinician's Guide to Inpatient Service: An Innovative Rapid Onboarding Strategy for the COVID-19 Pandemic

Background and Significance  When hospitals are subject to prolonged surges in patients, such as during the coronavirus disease 2019 (COVID-19) pandemic, additional clinicians may be needed to care for the rapid increase of acutely ill patients. How might we quickly prepare a large number of ambulatory-based clinicians to care for hospitalized patients using the inpatient workflow of the electronic health record (EHR)? Objectives  The aim of the study is to create a successful training intervention which prepares ambulatory-based clinicians as they transition to inpatient services. Methods  We created a training guide with embedded videos that describes the workflow of an inpatient clinician. We delivered this intervention via an e-mail hyperlink, a static hyperlink inside of the EHR, and an on-demand hyperlink within the EHR. Results  In anticipation of the first peak of inpatients with COVID-19 in April 2020, the training manual was accessed 261 times by 167 unique users as clinicians anticipated being called into service. As our institution has not yet needed to deploy ambulatory-based clinicians for inpatient service, usage data of the training document is still pending. Conclusion  We intend that our novel implementation of a multimedia, highly accessible onboarding document with access from points inside and outside of the EHR will improve clinician performance and serve as a helpful example to other organizations during the COVID-19 pandemic and beyond.     

Care models for mental health in a population of patients affected by COVID-19

ObjectiveEmergency psychological interventions are needed in patients with COVID-19. During the pandemic, psychological counseling services have been provided using online platforms to address adverse psychological impacts and symptoms in patients and the general population. We investigated the effects of telepsychotherapy on emotional well-being and psychological distress in patients affected by COVID-19.MethodsForty-five Sicilian patients who had contracted COVID-19 joined “Telecovid Sicilia” from March to June 2020. Participants completed self-assessment questionnaires and psychological testing to measure levels of anxiety, presence of depressive symptoms, and altered circadian rhythm with consequent sleep disorders and psychological distress. Individual telepsychotherapy services were provided for 1 hour, twice a week, for 16 sessions in total.ResultsWe enrolled 45 patients (42.2% women). We found significant changes between baseline and the end of follow-up in all outcome measures, especially depression (χ² (1) = 30.1; effect size [ES] = 0.82), anxiety (χ² (1) = 37.4; ES = 0.91), and paranoid ideation (χ² (1) = 5.6; ES = 0.35). The proportion of participants with sleep disorders decreased to 84.1% after intervention (χ² (1) = 58.6; ES = 1.14).ConclusionA telepsychotherapeutic approach showed promising effects on psychological symptoms, with significantly reduced patient anxiety and depression.     

COVID-19 Pandemic: The Role of EMS Physicians in a Community Response Effort

Abstract

The COVID-19 pandemic is a worldwide historical event that will continue to affect nearly every aspect of ordinary life, including affecting our economic, political, and healthcare eco-systems. An effective pandemic response demands a coordinated and integrated response across community healthcare stakeholders, including Public Health and Emergency Management Officials. EMS systems are in a unique position and perform an essential role on the frontlines of COVID-19, including facilitating coordination of response efforts to COVID-19 within their communities while supporting public health mitigation efforts to slow the spread of the SARS-CoV-2. EMS physicians serve their communities at a unique intersection as clinical leaders, population health experts, and advocates. This paper examines and recommends crucial roles for EMS physician leaders as communities work together in pandemic response.     

Moving Faster than the COVID-19 Pandemic: The Rapid,Digital Transformation of a Public Health System

Background  Queensland, Australia has been successful in containing the COVID-19 pandemic. Underpinning that response has been a highly effective virus containment strategy which relies on identification, isolation, and contact tracing of cases. The dramatic emergence of the COVID-19 pandemic rendered traditional paper-based systems for managing contact tracing no longer fit for purpose. A rapid digital transformation of the public health contact tracing system occurred to support this effort. Objectives  The objectives of the digital transformation were to shift legacy systems (paper or standalone electronic systems) to a digitally enabled public health system, where data are centered around the consumer rather than isolated databases. The objective of this paper is to outline this case study and detail the lessons learnt to inform and give confidence to others contemplating digitization of public health systems in response to the COVID-19 pandemic. Methods  This case study is set in Queensland, Australia. Universal health care is available. A multidisciplinary team was established consisting of clinical informaticians, developers, data strategists, and health information managers. An agile “pair-programming” approach was undertaken to application development and extensive change efforts were made to maximize adoption of the new digital workflows. Data governance and flows were changed to support rapid management of the pandemic. Results  The digital coronavirus application (DCOVA) is a web-based application that securely captures information about people required to quarantine and creates a multiagency secure database to support a successful containment strategy. Conclusion  Most of the literature surrounding digital transformation allows time for significant consultation, which was simply not possible under crisis conditions. Our observation is that staff was willing to adopt new digital systems because the reason for change (the COVID-19 pandemic) was clearly pressing. This case study highlights just how critical a unified purpose, is to successful, rapid digital transformation.     

Automated recognition of functioning,activity and participation in COVID-19 from electronic patient records by natural language processing: a proof- of- concept

PurposeTo address the feasibility, reliability and internal validity of natural language processing (NLP) for automated functional assessment of hospitalised COVID-19 patients in key International Classification of Functioning, Disability and Health (ICF) categories and levels from unstructured text in electronic health records (EHR) from a large teaching hospital.Materials and methodsEight human annotators assigned four ICF categories to relevant sentences: Emotional functions, Exercise tolerance, Walking and Moving, Work and Employment and their ICF levels (Functional Ambulation Categories for Walking and Moving, metabolic equivalents for Exercise tolerance). A linguistic neural network-based model was trained on 80% of the annotated sentences; inter-annotator agreement (IAA, Cohen’s kappa), a weighted score of precision and recall (F1) and RMSE for level detection were assessed for the remaining 20%.ResultsIn total 4112 sentences of non-COVID-19 and 1061 of COVID-19 patients were annotated. Average IAA was 0.81; F1 scores were 0.7 for Walking and Moving and Emotional functions; RMSE for Walking and Moving (5- level scale) was 1.17 for COVID-19 patients.ConclusionUsing a limited amount of annotated EHR sentences, a proof-of-concept was obtained for automated functional assessment of COVID-19 patients in ICF categories and levels. This allows for instantaneous assessment of the functional consequences of new diseases like COVID-19 for large numbers of patients.

Key messages

1. Hospitalised Covid-19 survivors may persistently suffer from low physical and mental functioning and a reduction in overall quality of life requiring appropriate and personalised rehabilitation strategies.
2. For this, assessment of functioning within multiple domains and categories of the International Classification of Function is required, which is cumbersome using structured data.
3. We show a proof-of-concept using Natural Language Processing techniques to automatically derive the aforementioned information from free-text notes within the Electronic Health Record of a large academic teaching hospital.

     

Impact of Changes in EHR Use during COVID-19 on Physician Trainee Mental Health

Objectives  This article investigates the association between changes in electronic health record (EHR) use during the coronavirus disease 2019 (COVID-19) pandemic on the rate of burnout, stress, posttraumatic stress disorder (PTSD), depression, and anxiety among physician trainees (residents and fellows). Methods  A total of 222 (of 1,375, 16.2%) physician trainees from an academic medical center responded to a Web-based survey. We compared the physician trainees who reported that their EHR use increased versus those whose EHR use stayed the same or decreased on outcomes related to depression, anxiety, stress, PTSD, and burnout using univariable and multivariable models. We examined whether self-reported exposure to COVID-19 patients moderated these relationships. Results  Physician trainees who reported increased use of EHR had higher burnout (adjusted mean, 1.48 [95% confidence interval [CI] 1.24, 1.71] vs. 1.05 [95% CI 0.93, 1.17]; p  = 0.001) and were more likely to exhibit symptoms of PTSD (adjusted mean = 15.09 [95% CI 9.12, 21.05] vs. 9.36 [95% CI 7.38, 11.28]; p  = 0.035). Physician trainees reporting increased EHR use outside of work were more likely to experience depression (adjusted mean, 8.37 [95% CI 5.68, 11.05] vs. 5.50 [95% CI 4.28, 6.72]; p  = 0.035). Among physician trainees with increased EHR use, those exposed to COVID-19 patients had significantly higher burnout (2.04, p  < 0.001) and depression scores (14.13, p  = 0.003). Conclusion  Increased EHR use was associated with higher burnout, depression, and PTSD outcomes among physician trainees. Although preliminary, these findings have implications for creating systemic changes to manage the wellness and well-being of trainees.     

Development of a Novel Communication Liaison Program to Support COVID-19 Patients and Their Families

In the spring of 2020, our hospital faced a surge of critically ill coronavirus disease 2019 patients, with intensive care unit (ICU) occupancy peaking at 204% of the baseline maximum capacity. In anticipation of this surge, we developed a remote communication liaison program to help the ICU and palliative care teams support families of critically ill patients. In just nine days from inception until implementation, we recruited and prepared ambulatory specialty providers to serve in this role effectively, despite minimal prior critical care experience. We report here the primary elements needed to reproduce and scale this program in other hospitals facing similar ICU surges, including a checklist for replication (Appendix I). Keys to success include strong logistical support, clinical reference material designed for rapid evolution, and a liaison team structure with peer coaching.     

The Impact of Mindful Meditation on Health Care Workers During the COVID-19 Pandemic

BackgroundThe COVID-19 pandemic placed a spotlight on health care workers as the world struggled with mental health crises. As the number of COVID-19 cases rose exponentially, this also paralleled health care workers’ perceived stress burden and increased risk for mental health trauma. This research project assessed the impact of a mobile mindful meditation application on health care workers’ perceived stress levels during a pandemic.MethodologyThrough quasi-experimental design, researchers assessed the effect of using a mobile mindful meditation (Synctuition) app on health care workers’ stress levels. Participants listened for 20 to 30 minutes daily for 30 days. Participants perceived stress levels were measured with Cohen’s Perceived Stress Scale.ResultsOf the 100 participants, there was a statistically significant decrease in perceived stress reduction between the groups across various categories. The pretest perceived stress scores were reduced from moderate to low stress postintervention after using the mindful meditation application.Implications for PracticeReducing stress in health care workers can potentially increase the quality of life for health care workers. and lowering stress levels can potentially improve the quality of care provided.     

Building a Learning Health System: Creating an Analytical Workflow for Evidence Generation to Inform Institutional Clinical Care Guidelines

Background  One key aspect of a learning health system (LHS) is utilizing data generated during care delivery to inform clinical care. However, institutional guidelines that utilize observational data are rare and require months to create, making current processes impractical for more urgent scenarios such as those posed by the COVID-19 pandemic. There exists a need to rapidly analyze institutional data to drive guideline creation where evidence from randomized control trials are unavailable. Objectives  This article provides a background on the current state of observational data generation in institutional guideline creation and details our institution''s experience in creating a novel workflow to (1) demonstrate the value of such a workflow, (2) demonstrate a real-world example, and (3) discuss difficulties encountered and future directions. Methods  Utilizing a multidisciplinary team of database specialists, clinicians, and informaticists, we created a workflow for identifying and translating a clinical need into a queryable format in our clinical data warehouse, creating data summaries and feeding this information back into clinical guideline creation. Results  Clinical questions posed by the hospital medicine division were answered in a rapid time frame and informed creation of institutional guidelines for the care of patients with COVID-19. The cost of setting up a workflow, answering the questions, and producing data summaries required around 300 hours of effort and $300,000 USD. Conclusion  A key component of an LHS is the ability to learn from data generated during care delivery. There are rare examples in the literature and we demonstrate one such example along with proposed thoughts of ideal multidisciplinary team formation and deployment.     

Nasal Foreign Body,an Unanticipated Complication of COVID-19 Care: A Case Report

BackgroundCoronavirus disease 2019 (COVID-19) has changed the way we practice medicine. Standards of care are evolving in an effort to diagnose, manage, and treat the cause of this global pandemic, as well as to protect the health care workforce. These practices can have unexpected and potentially dangerous consequences, particularly for patient populations with confounding factors that put them at increased risk for complications and poor outcomes.Case ReportA 52-year-old previously healthy woman presented with 4 days of nasal pain and discharge after using a home collection kit in an attempt to obtain a nasopharyngeal viral sample for COVID-19 testing.Why Should an Emergency Physician Be Aware of This?With treatments, policies, and procedures that are rapidly evolving and often deviating from established, evidence-based, usual care in response to the COVID-19 pandemic, emergency physicians must be cognizant of and monitor for poor outcomes and potential downstream complications, especially in underserved patient populations.     

Genesis of an emergency public drug information website by the French Society of Pharmacology and Therapeutics during the COVID-19 pandemic

On March 16, 2020, the French Society of Pharmacology and Therapeutics put online a national Question and Answer (Q&A) website, https://sfpt-fr.org/covid19 on the proper use of drugs during the COVID-19 pandemic. The working group ‘Drugs and COVID-19’ was composed of a scientific council, an editorial team, and experts in the field. The first questions were posted online during the first evening of home-confinement in France, March 17, 2020. Six weeks later, 140 Q&As have been posted. Questions on the controversial use of hydroxychloroquine and to a lesser extent concerning azithromycin have been the most consulted Q&As. Q&As have been consulted 226 014 times in 41 days. This large visibility was obtained through an early communication on Twitter, Facebook, traditional print, and web media. In addition, an early communication through the French Ministry of Health and the French National Agency for Medicines and Health Products Safety ANSM had a large impact in terms of daily number of views. There is a pressing need to sustain a public drug information service combining the expertise of scholarly pharmacology societies, pharmacovigilance network, and the Ministry of Health to quickly provide understandable, clear, expert answers to the general population’s concerns regarding COVID-19 and drug use and to counter fake news.     

Developing an mHealth Intervention to Reduce COVID-19–Associated Psychological Distress Among Health Care Workers in Nigeria: Protocol for a Design and Feasibility Study

BackgroundGlobally, COVID-19–related psychological distress is seriously eroding health care workers’ mental health and well-being, especially in low-income countries like Nigeria. The use of mobile health (mHealth) interventions is now increasingly recognized as an innovative approach that may improve mental health and well-being. This project aims to develop an mHealth psychological intervention (mPsyI) to reduce COVID-19–related psychological distress among health care workers in Nigeria.ObjectiveOur objective is to present a study protocol to determine the level of COVID-19–related psychological distress among health care workers in Nigeria; explore health care workers’ experience of COVID-19–related psychological distress; develop and pilot test mPsyI to reduce this distress; and assess the feasibility of this intervention (such as usability, engagement, and satisfaction).MethodsA mixed (quantitative and qualitative) methods approach is used in which health care workers will be recruited from 2 tertiary health care facilities in southwest Nigeria. The study is divided into 4 phases based on the study objectives. Phase 1 involves a quantitative survey to assess the type and levels of psychosocial distress. Phase 2 collects qualitative data on psychosocial distress among health care workers. Phase 3 involves development of the mHealth-based psychological intervention, and phase 4 is a mixed methods study to assess the feasibility and acceptability of the intervention.ResultsThis study was funded in November 2020 by the Global Effort on COVID-19 Health Research, and collection of preliminary baseline data started in July 2021.ConclusionsThis is the first study to report the development of an mHealth-based intervention to reduce COVID-19–related psychological distress among health care workers in Nigeria. Using a mixed methods design in this study can potentially facilitate the adaptation of an evidence-based treatment method that is culturally sensitive and cost-effective for the management of COVID-19–related psychological distress among health care workers in Nigeria.International Registered Report Identifier (IRRID)DERR1-10.2196/36174     

The Bulle: Support and Prevention of Psychological Decompensation of Health Care Workers During the Trauma of the COVID-19 Epidemic

The coronavirus disease 2019 pandemic presents unprecedented challenges for the health care system. The pressure on health care staff continues to intensify, accentuated by the confinement (lockdown) of the population and the unprecedented duration of this emergency. Separately and especially together, overwork, degraded conditions of care because of the never-ending emergency, and the risk of exposure to the virus can lead to acute psychological distress or signs of burnout.This original program was developed at Cochin Hospital in Paris, France to prevent these potentially dramatic psychological consequences, support the medical staff, and identify those most affected to offer them specific care. A program and a space for relaxation and support for hospital caregivers by hospital caregivers, the Port Royal Bulle (the Bubble) offers these workers help in decompression and relaxation. It combines a warm and caring welcome that promotes attention, listening, conversations, and exchanges as needed, empathetic support, and the ability to participate in soothing, relaxing, or low-impact physical activities. It takes care of caregivers. The Bubble is a program that is simple to set up and that appears to meet professionals' expectations. Making it permanent and enlarging its scale, as a complement to existing programs, might help to support health care personnel in their work.     

Transition of Nurse Practitioner Faculty Practice and Student Clinicals to Telehealth: Response to the COVID-19 Pandemic

The COVID-19 pandemic forced the US health care system to evaluate alternative care delivery strategies to reduce the risk of coronavirus transmission to patients and health care providers. Telehealth modalities are a safe and effective alternative to face-to-face visits for primary and psychiatric care. Federal policy makers approved changes to telehealth reimbursement coverage and allowed flexibility of location for patients and providers. This article describes the transition of patient visits to telehealth by nurse practitioner faculty at an academic medical center to maintain continuity of care of underserved patient populations. This pivot facilitated resumption of clinical learning experiences for nurse practitioner students.