Publications by authors named "Gretchen P Jackson"

31 Publications

Parent Activation in the Neonatal Intensive Care Unit.

Am J Perinatol 2021 Oct 12. Epub 2021 Oct 12.

Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee.

Objective:  Patient activation is the knowledge, skills, and confidence to manage one's health; parent activation is a comparable concept related to a parent's ability to manage a child's health. Activation in adults is a modifiable risk factor and associated with clinical outcomes and health care utilization. We examined activation in parents of hospitalized newborns observing temporal trends and associations with sociodemographic characteristics, neonate characteristics, and outcomes.

Study Design:  Participants included adult parents of neonates admitted to a level-IV neonatal intensive care unit in an academic medical center. Activation was measured with the 10-item Parent version of the Patient Activation Measure (P-PAM) at admission, discharge, and 30 days after discharge. Associations with sociodemographic variables, health literacy, clinical variables, and health care utilization were evaluated.

Results:  A total of 96 adults of 64 neonates were enrolled. The overall mean P-PAM score on admission was 81.8 (standard deviation [SD] = 18), 88.8 (SD = 13) at discharge, and 86.8 (SD = 16) at 30-day follow-up. Using linear mixed regression model, P-PAM score was significantly associated with timing of measurement. Higher P-PAM scores were associated with higher health literacy ( = 0.002) and higher in mothers compared to fathers ( = 0.040). There were no significant associations of admission P-PAM scores with sociodemographic characteristics. Parents of neonates who had a surgical diagnosis had a statistically significant ( = 0.003) lower score than those who did not. There were no associations between discharge P-PAM scores and neonates' lengths of stay or other indicators of illness severity.

Conclusion:  Parental activation in the NICU setting was higher than reported in the adult and limited pediatric literature; scores increased from admission to discharge and 30-day postdischarge. Activation was higher in mothers and parents with higher health literacy. Additional larger scale studies are needed to determine whether parental activation is associated with long-term health care outcomes as seen in adults.

Key Points: · Little is known about activation in parents of neonates.. · Activation plays a role in health outcomes in adults.. · Larger studies are needed to explore parent activation..
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http://dx.doi.org/10.1055/s-0041-1736294DOI Listing
October 2021

Differences in information accessed in a pharmacologic knowledge base using a conversational agent vs traditional search methods.

Int J Med Inform 2021 09 16;153:104530. Epub 2021 Jul 16.

IBM Watson Health, Cambridge, MA, USA; Vanderbilt University Medical Center, Nashville, TN, USA.

Introduction: Clinicians rely on pharmacologic knowledge bases to answer medication questions and avoid potential adverse drug events. In late 2018, an artificial intelligence-based conversational agent, Watson Assistant (WA), was made available to online subscribers to the pharmacologic knowledge base, Micromedex®. WA allows users to ask medication-related questions in natural language. This study evaluated search method-dependent differences in the frequency of information accessed by traditional methods (keyword search and heading navigation) vs conversational agent search.

Materials And Methods: We compared the proportion of information types accessed through the conversational agent to the proportion of analogous information types accessed by traditional methods during the first 6 months of 2020.

Results: Addition of the conversational agent allowed early adopters to access 22 different information types contained in the 'quick answers' portion of the knowledge base. These information types were accessed 117,550 times with WA during the study period, compared to 33,649,651 times using traditional search methods. The distribution across information types differed by method employed (c test, P < .0001). Single drug/dosing, FDA/non-FDA uses, adverse effects, and drug administration emerged as 4 of the top 5 information types accessed by either method. Intravenous compatibility was accessed more frequently using the conversational agent (7.7% vs. 0.6% for traditional methods), whereas dose adjustments were accessed more frequently via traditional methods (4.8% vs. 1.4% for WA).

Conclusion: In a widely used pharmacologic knowledge base, information accessed through conversational agents versus traditional methods differed. User-centered studies are needed to understand these differences.
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http://dx.doi.org/10.1016/j.ijmedinf.2021.104530DOI Listing
September 2021

Effectiveness of non-pharmaceutical interventions related to social distancing on respiratory viral infectious disease outcomes: A rapid evidence-based review and meta-analysis.

SAGE Open Med 2021 6;9:20503121211022973. Epub 2021 Jun 6.

IBM Watson Health , Cambridge, MA, USA.

Objectives: Non-pharmaceutical interventions (e.g. quarantine and isolation) are used to mitigate and control viral infectious disease, but their effectiveness has not been well studied. For COVID-19, disease control efforts will rely on non-pharmaceutical interventions until pharmaceutical interventions become widely available, while non-pharmaceutical interventions will be of continued importance thereafter.

Methods: This rapid evidence-based review provides both qualitative and quantitative analyses of the effectiveness of social distancing non-pharmaceutical interventions on disease outcomes. Literature was retrieved from MEDLINE, Google Scholar, and pre-print databases (BioRxiv.org, MedRxiv.org, and Wellcome Open Research).

Results: Twenty-eight studies met inclusion criteria ( = 28). Early, sustained, and combined application of various non-pharmaceutical interventions could mitigate and control primary outbreaks and prevent more severe secondary or tertiary outbreaks. The strategic use of non-pharmaceutical interventions decreased incidence, transmission, and/or mortality across all interventions examined. The pooled attack rates for no non-pharmaceutical intervention, single non-pharmaceutical interventions, and multiple non-pharmaceutical interventions were 42% (95% confidence interval = 30% - 55%), 29% (95% confidence interval = 23% - 36%), and 22% (95% confidence interval = 16% - 29%), respectively.

Conclusion: Implementation of multiple non-pharmaceutical interventions at key decision points for public health could effectively facilitate disease mitigation and suppression until pharmaceutical interventions become available. Dynamics around values, the susceptibility of certain high-risk patient groups to infection, and the probability of asymptomatic cases spreading disease should be considered.
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http://dx.doi.org/10.1177/20503121211022973DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8188982PMC
June 2021

Artificial intelligence in oncology: Path to implementation.

Cancer Med 2021 06 7;10(12):4138-4149. Epub 2021 May 7.

Harvard Medical School, Boston, MA, USA.

In recent years, the field of artificial intelligence (AI) in oncology has grown exponentially. AI solutions have been developed to tackle a variety of cancer-related challenges. Medical institutions, hospital systems, and technology companies are developing AI tools aimed at supporting clinical decision making, increasing access to cancer care, and improving clinical efficiency while delivering safe, high-value oncology care. AI in oncology has demonstrated accurate technical performance in image analysis, predictive analytics, and precision oncology delivery. Yet, adoption of AI tools is not widespread, and the impact of AI on patient outcomes remains uncertain. Major barriers for AI implementation in oncology include biased and heterogeneous data, data management and collection burdens, a lack of standardized research reporting, insufficient clinical validation, workflow and user-design challenges, outdated regulatory and legal frameworks, and dynamic knowledge and data. Concrete actions that major stakeholders can take to overcome barriers to AI implementation in oncology include training and educating the oncology workforce in AI; standardizing data, model validation methods, and legal and safety regulations; funding and conducting future research; and developing, studying, and deploying AI tools through multidisciplinary collaboration.
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http://dx.doi.org/10.1002/cam4.3935DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8209596PMC
June 2021

Barriers to Prescribing Targeted Therapies for Patients With NSCLC With Highly Actionable Gene Variants in the Veterans Affairs National Precision Oncology Program.

JCO Oncol Pract 2021 07 29;17(7):e1012-e1020. Epub 2021 Mar 29.

Durham Veterans Affairs Medical Center, Division of Hematology and Oncology, Durham, NC.

Purpose: Next-generation sequencing (NGS) gene panels are frequently completed for patients with advanced non-small-cell lung cancer (NSCLC). Patients with highly actionable gene variants have improved outcomes and reduced toxicities with the use of corresponding targeted agents. We sought to identify barriers to targeted agent use within the Veterans Health Affairs' National Precision Oncology Program (NPOP).

Methods: A retrospective evaluation of patients with NSCLC who underwent NGS multigene panels through NPOP between July 2015 and February 2019 was conducted. Patients who were assigned level 1 or 2A evidence for oncogenic gene variants by an artificial intelligence offering (IBM Watson for Genomics [WfG]) and NPOP staff were selected. Antineoplastic drug prescriptions and provider notes were reviewed. Reasons for withholding targeted treatments were categorized.

Results: Of 1,749 patients with NSCLC who successfully underwent NGS gene panel testing, 112 (6.4%) patients were assigned level 1 and/or 2A evidence for available targeted treatments by WfG and NPOP staff. All highly actionable gene variants were within , , , , , , and . Of these, 36 (32.1%) patients were not prescribed targeted agents. The three most common reasons were (1) patient did not carry a diagnosis of metastatic disease (33.3%), (2) treating provider did not comment on the NGS results (25.0%), and (3) provider felt that patient could not tolerate therapy (19.4%). No patients were denied access to level 1 or 2A targeted drugs because of rejection of a nonformulary drug request.

Conclusion: A substantial minority of patients with NSCLC bearing highly actionable gene variants are not prescribed targeted agents. Further provider- and pathologist-directed educational efforts and implementation of health informatics systems to provide real-time decision support for test ordering and interpretation are needed.
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http://dx.doi.org/10.1200/OP.20.00703DOI Listing
July 2021

The Perceived Impact and Usability of a Care Management and Coordination System in Delivering Services to Vulnerable Populations: Mixed Methods Study.

J Med Internet Res 2021 03 12;23(3):e24122. Epub 2021 Mar 12.

IBM Watson Health, Cambridge, MA, United States.

Background: People with complex needs, such as those experiencing homelessness, require concurrent, seamless support from multiple social service agencies. Sonoma County, California has one of the nation's largest homeless populations among largely suburban communities. To support client-centered care, the county deployed a Care Management and Coordination System (CMCS). This system comprised the Watson Care Manager (WCM), a front-end system, and Connect 360, which is an integrated data hub that aggregates information from various systems into a single client record.

Objective: The aim of this study is to evaluate the perceived impact and usability of WCM in delivering services to the homeless population in Sonoma County.

Methods: A mixed methods study was conducted to identify ways in which WCM helps to coordinate care. Interviews, observations, and surveys were conducted, and transcripts and field notes were thematically analyzed and directed by a grounded theory approach. Responses to the Technology Acceptance Model survey were analyzed.

Results: A total of 16 participants were interviewed, including WCM users (n=8) and department leadership members (n=8). In total, 3 interdisciplinary team meetings were observed, and 8 WCM users were surveyed. WCM provided a central shared platform where client-related, up-to-date, comprehensive, and reliable information from participating agencies was consolidated. Factors that facilitated WCM use were users' enthusiasm regarding the tool functionalities, scalability, and agency collaboration. Constraining factors included the suboptimal awareness of care delivery goals and functionality of the system among the community, sensitivities about data sharing and legal requirements, and constrained funding from government and nongovernment organizations. Overall, users found WCM to be a useful tool that was easy to use and helped to enhance performance.

Conclusions: WCM supports the delivery of care to individuals with complex needs. Integration of data and information in a CMCS can facilitate coordinated care. Future research should examine WCM and similar CMCSs in diverse populations and settings.
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http://dx.doi.org/10.2196/24122DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7998322PMC
March 2021

The burden of the digital environment: a systematic review on organization-directed workplace interventions to mitigate physician burnout.

J Am Med Inform Assoc 2021 04;28(5):985-997

Center for AI, Research, and Evaluation, IBM Watson Health, Cambridge, Massachusetts, USA.

Objective: To conduct a systematic review identifying workplace interventions that mitigate physician burnout related to the digital environment including health information technologies (eg, electronic health records) and decision support systems) with or without the application of advanced analytics for clinical care.

Materials And Methods: Literature published from January 1, 2007 to June 3, 2020 was systematically reviewed from multiple databases and hand searches. Subgroup analysis identified relevant physician burnout studies with interventions examining digital tool burden, related workflow inefficiencies, and measures of burnout, stress, or job satisfaction in all practice settings.

Results: The search strategy identified 4806 citations of which 81 met inclusion criteria. Thirty-eight studies reported interventions to decrease digital tool burden. Sixty-eight percent of these studies reported improvement in burnout and/or its proxy measures. Burnout was decreased by interventions that optimized technologies (primarily electronic health records), provided training, reduced documentation and task time, expanded the care team, and leveraged quality improvement processes in workflows.

Discussion: The contribution of digital tools to physician burnout can be mitigated by careful examination of usability, introducing technologies to save or optimize time, and applying quality improvement to workflows.

Conclusion: Physician burnout is not reduced by technology implementation but can be mitigated by technology and workflow optimization, training, team expansion, and careful consideration of factors affecting burnout, including specialty, practice setting, regulatory pressures, and how physicians spend their time.
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http://dx.doi.org/10.1093/jamia/ocaa301DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8068437PMC
April 2021

Health Management in the Home: A Qualitative Study of Pregnant Women and Their Caregivers.

J Patient Exp 2020 Dec 14;7(6):1227-1233. Epub 2020 Aug 14.

Department of Biomedical Informatics, Vanderbilt University, Nashville, TN, USA.

With growth in consumer health technologies, patients and caregivers have become increasingly involved in their health and medical care. Such health-related engagement often occurs at home. Pregnancy is a common condition and, for many women, their first exposure to health management practices. This study examined how pregnant women and caregivers managed health in their homes. Participants completed sociodemographic surveys and semi-structured interviews about living situation, information needs, and technology use. Using an iterative, inductive coding approach, we identified themes about health management, including the physical home, help at home, community, the virtual home, and biggest concerns. Most expectant mothers encountered everyday problems with mobility and household management. Pregnant women desired more assistance from caregivers, who often did not know how to help. Caregivers who provided help took on new roles. Many expectant families did not trust advice found online. Over half of expectant families had biggest concerns that involved the home.
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http://dx.doi.org/10.1177/2374373520948442DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7786694PMC
December 2020

Artificial Intelligence Clinical Evidence Engine for Automatic Identification, Prioritization, and Extraction of Relevant Clinical Oncology Research.

JCO Clin Cancer Inform 2021 01;5:102-111

IBM Watson Health, IBM Corporation, Cambridge, MA.

Purpose: We developed a system to automate analysis of the clinical oncology scientific literature from bibliographic databases and match articles to specific patient cohorts to answer specific questions regarding the efficacy of a treatment. The approach attempts to replicate a clinician's mental processes when reviewing published literature in the context of a patient case. We describe the system and evaluate its performance.

Methods: We developed separate ground truth data sets for each of the tasks described in the paper. The first ground truth was used to measure the natural language processing (NLP) accuracy from approximately 1,300 papers covering approximately 3,100 statements and approximately 25 concepts; performance was evaluated using a standard F1 score. The ground truth for the expert classifier model was generated by dividing papers cited in clinical guidelines into a training set and a test set in an 80:20 ratio, and performance was evaluated for accuracy, sensitivity, and specificity.

Results: The NLP models were able to identify individual attributes with a 0.7-0.9 F1 score, depending on the attribute of interest. The expert classifier machine learning model was able to classify the individual records with a 0.93 accuracy (95% CI, 0.9 to 0.96, < .0001), and sensitivity and specificity of 0.95 and 0.91, respectively. Using a decision boundary of 0.5 for the positive (expert) label, the classifier demonstrated an F1 score of 0.92.

Conclusion: The system identified and extracted evidence from the oncology literature with a high degree of accuracy, sensitivity, and specificity. This tool enables timely access to the most relevant biomedical literature, providing critical support to evidence-based practice in areas of rapidly evolving science.
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http://dx.doi.org/10.1200/CCI.20.00087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8140792PMC
January 2021

Predictive article recommendation using natural language processing and machine learning to support evidence updates in domain-specific knowledge graphs.

JAMIA Open 2020 Oct 29;3(3):332-337. Epub 2020 Sep 29.

IBM Watson Health, Cambridge, Massachusetts, USA.

Objectives: Describe an augmented intelligence approach to facilitate the update of evidence for associations in knowledge graphs.

Methods: New publications are filtered through multiple machine learning study classifiers, and filtered publications are combined with articles already included as evidence in the knowledge graph. The corpus is then subjected to named entity recognition, semantic dictionary mapping, term vector space modeling, pairwise similarity, and focal entity match to identify highly related publications. Subject matter experts review recommended articles to assess inclusion in the knowledge graph; discrepancies are resolved by consensus.

Results: Study classifiers achieved F-scores from 0.88 to 0.94, and similarity thresholds for each study type were determined by experimentation. Our approach reduces human literature review load by 99%, and over the past 12 months, 41% of recommendations were accepted to update the knowledge graph.

Conclusion: Integrated search and recommendation exploiting current evidence in a knowledge graph is useful for reducing human cognition load.
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http://dx.doi.org/10.1093/jamiaopen/ooaa028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7660962PMC
October 2020

A Narrative Review of Emerging Therapeutics for COVID-19.

Mayo Clin Proc Innov Qual Outcomes 2020 Dec 20;4(6):745-758. Epub 2020 Jul 20.

Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN.

The novel severe acute respiratory syndrome coronavirus 2, the causal agent of coronavirus disease 2019 (COVID-19), quickly spread around the world, resulting in the most aggressive pandemic experienced in more than 100 years. Research on targeted therapies and vaccines has been initiated on an unprecedented scale and speed but will take months and even years to come to fruition. Meanwhile, the efficacy of emerging therapeutics for use in treating COVID-19 is feverishly being investigated to identify the best available treatment options for dealing with the current wave of disease. This review of publications with a "treatment" tag through June 29, 2020 in the National Library of Medicine's LitCovid literature hub, provides frontline clinicians with a pragmatic summary of the current state of the rapidly evolving evidence supporting emerging candidate therapeutics for COVID-19. Two main categories of pharmaceutical therapeutics are showing promise: those with antiviral activity directly addressing infection and those that counteract the inflammatory cytokine storm induced by severe disease. Preliminary results suggest that other approaches such as convalescent plasma therapy and lung radiation therapy may have some efficacy. The current clinical evidence for potential treatments is preliminary-often small retrospective series or early results of randomized trials-and the science is evolving rapidly. The long-term results from large, well-designed randomized controlled trials will provide definitive evidence for therapeutic effectiveness and are likely months away. The trial landscape for promising therapies is described.
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http://dx.doi.org/10.1016/j.mayocpiqo.2020.07.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7369591PMC
December 2020

Medical oncologists' perspectives of the Veterans Affairs National Precision Oncology Program.

PLoS One 2020 24;15(7):e0235861. Epub 2020 Jul 24.

Center for Cognitive Sciences in Medicine and Public Health, The New York Academy of Medicine, New York City, NY, United States of America.

Background: To support the rising need for testing and to standardize tumor DNA sequencing practices within the U.S. Department of Veterans Affairs (VA)'s Veterans Health Administration (VHA), the National Precision Oncology Program (NPOP) was launched in 2016. We sought to assess oncologists' practices, concerns, and perceptions regarding Next-Generation Sequencing (NGS) and the NPOP.

Materials And Methods: Using a purposive total sampling approach, oncologists who had previously ordered NGS for at least one tumor sample through the NPOP were invited to participate in semi-structured interviews. Questions assessed the following: expectations for the NPOP, procedural requirements, applicability of testing results, and the summative utility of the NPOP. Interviews were assessed using an open coding approach. Thematic analysis was conducted to evaluate the completed codebook. Themes were defined deductively by reviewing the direct responses to interview questions as well as inductively by identifying emerging patterns of data.

Results: Of the 105 medical oncologists who were invited to participate, 20 (19%) were interviewed from 19 different VA medical centers in 14 states. Five recurrent themes were observed: (1) Educational Efforts Regarding Tumor DNA Sequencing Should be Undertaken, (2) Pathology Departments Share a Critical Role in Facilitating Test Completion, (3) Tumor DNA Sequencing via NGS Serves as the Most Comprehensive Testing Modality within Precision Oncology, (4) The Availability of the NPOP Has Expanded Options for Select Patients, and (5) The Completion of Tumor DNA Sequencing through the NPOP Could Help Improve Research Efforts within VHA Oncology Practices.

Conclusion: Medical oncologists believe that the availability of tumor DNA sequencing through the NPOP could potentially lead to an improvement in outcomes for veterans with metastatic solid tumors. Efforts should be directed toward improving oncologists' understanding of sequencing, strengthening collaborative relationships between oncologists and pathologists, and assessing the role of comprehensive NGS panels within the battery of precision tests.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0235861PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7380614PMC
September 2020

Automating the Classification of Complexity of Medical Decision-Making in Patient-Provider Messaging in a Patient Portal.

J Surg Res 2020 11 19;255:224-232. Epub 2020 Jun 19.

Vanderbilt University Medical Center, Nashville, Tennessee; IBM Watson Health, IBM, Cambridge, Massachusetts.

Background: Patient portals are consumer health applications that allow patients to view their health information. Portals facilitate the interactions between patients and their caregivers by offering secure messaging. Patients communicate different needs through portal messages. Medical needs contain requests for delivery of care (e.g. reporting new symptoms). Automating the classification of medical decision complexity in portal messages has not been investigated.

Materials And Methods: We trained two multiclass classifiers, multinomial Naïve Bayes and random forest on 500 message threads, to quantify and label the complexity of decision-making into four classes: no decision, straightforward, low, and moderate. We compared the performance of the models to using only the number of medical terms without training a machine learning model.

Results: Our analysis demonstrated that machine learning models have better performance than the model that did not use machine learning. Moreover, machine learning models could quantify the complexity of decision-making that the messages contained with 0.59, 0.45, and 0.58 for macro, micro, and weighted precision and 0.63,0.41, and 0.63 for macro, micro, and weighted recall.

Conclusions: This study is one of the first to attempt to classify patient portal messages by whether they involve medical decision-making and the complexity of that decision-making. Machine learning classifiers trained on message content resulted in better message thread classification than classifiers that employed medical terms in the messages alone.
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http://dx.doi.org/10.1016/j.jss.2020.05.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7303623PMC
November 2020

Artificial Intelligence Tool for Optimizing Eligibility Screening for Clinical Trials in a Large Community Cancer Center.

JCO Clin Cancer Inform 2020 01;4:50-59

US Oncology Medical, Novartis Pharmaceuticals Corporation, East Hanover, NJ.

Purpose: Less than 5% of patients with cancer enroll in clinical trials, and 1 in 5 trials are stopped for poor accrual. We evaluated an automated clinical trial matching system that uses natural language processing to extract patient and trial characteristics from unstructured sources and machine learning to match patients to clinical trials.

Patients And Methods: Medical records from 997 patients with breast cancer were assessed for trial eligibility at Highlands Oncology Group between May and August 2016. System and manual attribute extraction and eligibility determinations were compared using the percentage of agreement for 239 patients and 4 trials. Sensitivity and specificity of system-generated eligibility determinations were measured, and the time required for manual review and system-assisted eligibility determinations were compared.

Results: Agreement between system and manual attribute extraction ranged from 64.3% to 94.0%. Agreement between system and manual eligibility determinations was 81%-96%. System eligibility determinations demonstrated specificities between 76% and 99%, with sensitivities between 91% and 95% for 3 trials and 46.7% for the 4th. Manual eligibility screening of 90 patients for 3 trials took 110 minutes; system-assisted eligibility determinations of the same patients for the same trials required 24 minutes.

Conclusion: In this study, the clinical trial matching system displayed a promising performance in screening patients with breast cancer for trial eligibility. System-assisted trial eligibility determinations were substantially faster than manual review, and the system reliably excluded ineligible patients for all trials and identified eligible patients for most trials.
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http://dx.doi.org/10.1200/CCI.19.00079DOI Listing
January 2020

Association of Genetic Risk of Obesity with Postoperative Complications Using Mendelian Randomization.

World J Surg 2020 01;44(1):84-94

The Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.

Background: The extent to which obesity and genetics determine postoperative complications is incompletely understood.

Methods: We performed a retrospective study using two population cohorts with electronic health record (EHR) data. The first included 736,726 adults with body mass index (BMI) recorded between 1990 and 2017 at Vanderbilt University Medical Center. The second cohort consisted of 65,174 individuals from 12 institutions contributing EHR and genome-wide genotyping data to the Electronic Medical Records and Genomics (eMERGE) Network. Pairwise logistic regression analyses were used to measure the association of BMI categories with postoperative complications derived from International Classification of Disease-9 codes, including postoperative infection, incisional hernia, and intestinal obstruction. A genetic risk score was constructed from 97 obesity-risk single-nucleotide polymorphisms for a Mendelian randomization study to determine the association of genetic risk of obesity on postoperative complications. Logistic regression analyses were adjusted for sex, age, site, and race/principal components.

Results: Individuals with overweight or obese BMI (≥25 kg/m) had increased risk of incisional hernia (odds ratio [OR] 1.7-5.5, p < 3.1 × 10), and people with obesity (BMI ≥ 30 kg/m) had increased risk of postoperative infection (OR 1.2-2.3, p < 2.5 × 10). In the eMERGE cohort, genetically predicted BMI was associated with incisional hernia (OR 2.1 [95% CI 1.8-2.5], p = 1.4 × 10) and postoperative infection (OR 1.6 [95% CI 1.4-1.9], p = 3.1 × 10). Association findings were similar after limitation of the cohorts to those who underwent abdominal procedures.

Conclusions: Clinical and Mendelian randomization studies suggest that obesity, as measured by BMI, is associated with the development of postoperative incisional hernia and infection.
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http://dx.doi.org/10.1007/s00268-019-05202-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6925615PMC
January 2020

Communication Technology Use and Preferences for Pregnant Women and Their Caregivers.

AMIA Annu Symp Proc 2018 5;2018:1515-1523. Epub 2018 Dec 5.

Vanderbilt University Medical Center, Nashville, TN.

The rapid evolution of communication technologies has created new ways for healthcare consumers to manage their health. In a mixed-methods study, we examined technology use and willingness to use in pregnant women and caregivers, using surveys and semi-structured interviews. Most participants had used text messaging, automated phone calls, Skype/FaceTime, social media, and online discussion forums. To communicate with healthcare providers, most were willing to use text messaging and had not, but desired to use Skype/FaceTime. Fewer were willing to use social media or online discussion forums due to concerns about privacy and security. Most were willing to use text messaging, Skype/FaceTime, or online discussion forums to support health in other ways, but few had done so. About half were willing to use automated phone calls, but most did not like them due to the impersonal nature and time required. Developers should consider such preferences in design of health information technologies.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6371273PMC
January 2020

Development of a Technology-Supported, Lay Peer-to-Peer Family Engagement Consultation Service in a Pediatric Hospital.

AMIA Annu Symp Proc 2018 5;2018:730-739. Epub 2018 Dec 5.

Vanderbilt University Medical Center, Nashville, Tennessee.

Patient and caregiver engagement in making decisions and taking actions to promote health are critically important for improving outcomes, enhancing healthcare experience satisfaction, and reducing costs. Patients and caregivers have a wealth of expertise in illness self-management and can aid others in attaining high levels of activation through peer-to-peer social support. We describe the development of a technology-supported, family engagement consultation service at Children's of Alabama that integrates parent volunteers as front-line, peer-to-peer support consultants with a multidisciplinary team of informatics professionals in the pediatric hospital setting. This service was adapted from an existing engagement consultation service with a traditional medical consultation model at Vanderbilt Children's Hospital. The unique features of the new model are articulated, along with plans for a shared knowledge database of consumer health resources to meet needs. The layperson peer-to-peer design is highly innovative and relevant as healthcare transitions towards increasingly participatory and personalized medicine.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6371240PMC
November 2019

Care Delivered by Pediatric Surgical Specialties Through Patient Portal Messaging.

J Surg Res 2019 02 11;234:231-239. Epub 2018 Oct 11.

Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.

Background: Patient portals are online applications that typically allow users to interact with providers using secure messaging. Portal messaging use and content have not been studied in pediatric surgical specialties.

Materials And Methods: We obtained all message threads initiated by pediatric patients/caregivers and sent to pediatric surgical providers through the Vanderbilt University Medical Center patient portal from June 1, 2014 to December 31, 2014. We collected patient demographics and providers' surgical specialties. We determined the number of message threads and individual messages sent by patients/caregivers and providers by specialty. Message content was analyzed by semantic types using a validated consumer health taxonomy.

Results: Most threads were about male (176, 60.3%), white (239, 81.8%), non-Hispanic (278, 95.2%) patients with a median age of 6 y (range: 0-21 y). A total of 292 message threads containing 1679 individual messages were sent with mean 5.8 (standard deviation [SD] 5.0) messages per thread. Messages were sent more frequently regarding younger patients (P = 0.001). Physicians directly contributed to 161 (55%) message threads. Otolaryngology received the most threads (123, 42.1%) and messages (790, 47.1%). Specialties exchanging the most messages per thread were cardiac surgery (mean 7.0, SD 11.7), and dermatology (7.0, SD 6.9). Most message threads (273, 93.5%) involved delivery of medical care with 123 (42.1%) involving appointments/scheduling; 99 (33.9%) medical problems; 81 (27.7%) treatments; 68 (23.3%) testing; and 29 (9.9%) referrals.

Conclusions: Pediatric surgeons deliver substantial care within portal messages exchanged with pediatric patients and caregivers. Institutions adopting portals should consider effects on provider workload and potential disparities in access to care.
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http://dx.doi.org/10.1016/j.jss.2018.09.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6294474PMC
February 2019

Consumer health-related needs of pregnant women and their caregivers.

JAMIA Open 2018 Jul 18;1(1):57-66. Epub 2018 Jun 18.

Department of Surgery, Vanderbilt University Medical Center, 1161 21st Ave S, CCC-4312 MCN, Nashville, Tennessee 37232-2730, USA.

Objectives: To build effective applications, technology designers must understand consumer health needs. Pregnancy is a common health condition, and expectant families have unanswered questions. This study examined consumer health-related needs in pregnant women and caregivers and determined the types of needs that were not met.

Materials And Methods: We enrolled pregnant women <36 weeks' gestational age and caregivers from advanced maternal-fetal and group prenatal care settings. Participant characteristics were collected through surveys, and health-related needs were elicited in semi-structured interviews. Researchers categorized needs by semantic type and whether they were met (ie, met, partially met, or unmet). Inter-rater reliability was measured by Cohen's kappa.

Results: Seventy-one pregnant women and 29 caregivers participated and reported 1054 needs, 28% unmet, and 49% partially met. Need types were 66.2% informational, 15.9% logistical, 8.9% social, 8.6% medical, and 0.3% other. Inter-rater reliability was near perfect (=0.95,  < 0.001).

Discussion: Common topics of unmet needs were prognosis, life management, and need for emotional support. For pregnant women, these unmet needs focused around being healthy, childbirth, infant care, and being a good mother; caregivers' needs involved caring for the mother, the natural course of pregnancy, and life after pregnancy.

Conclusion: Pregnant women and caregivers have a rich set of health-related needs with many not fully met. Caregivers' needs differed from those of pregnant women and may not be adequately addressed by resources designed for mothers. Many unmet needs involved stress and life management. Knowledge about consumer health needs can inform the design of better technologies for pregnancy.
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http://dx.doi.org/10.1093/jamiaopen/ooy018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6241505PMC
July 2018

Leveraging Health Information Technologies to Support Surgical Practice.

JAMA Surg 2018 11;153(11):981-982

Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis.

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http://dx.doi.org/10.1001/jamasurg.2018.1978DOI Listing
November 2018

Common Consumer Health-Related Needs in the Pediatric Hospital Setting: Lessons from an Engagement Consultation Service.

Appl Clin Inform 2018 07 8;9(3):595-603. Epub 2018 Aug 8.

Department of Biomedical Informatics, Vanderbilt University Medical Center, Vanderbilt University, Nashville, Tennessee, United States.

Background: Informed and engaged parents may influence outcomes for childhood illness. Understanding the needs of the caregivers of pediatric patients is a critical first step in promoting engagement in their child's care. In 2014, we developed an Engagement Consultation Service at the Monroe Carell Jr. Children's Hospital at Vanderbilt. This service determines the health-related needs of the caregivers of hospitalized children and makes educational or technology recommendations to meet those needs and support engagement.

Objectives: This report describes the most common health-related needs identified in the caregivers of hospitalized pediatric patients and details the recommended interventions to meet those needs.

Methods: The most commonly reported consumer health-related needs from our 3-year experience with the Engagement Consultation Service were extracted from consultations notes. Each need was classified by semantic type using a taxonomy of consumer health needs. Typical recommendations for each need and their administration were detailed.

Results: The most frequently recognized needs involved communicating with health care providers after discharge, using medical devices, distinguishing between benign and concerning symptoms, knowing what questions to ask providers and remembering them, finding trustworthy sources of information online, understanding disease prognosis, and getting emotional support. A variety of apps, Web sites, printed materials, and online groups were recommended.

Conclusion: The parents of hospitalized patients share several common health-related needs that can be addressed with educational and technology interventions. An inpatient Engagement Consultation Service provides a generalizable framework for identifying health-related needs and delivers tools to meet those needs and promote engagement during and after hospitalizations.
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http://dx.doi.org/10.1055/s-0038-1667205DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6082659PMC
July 2018

Barriers, Facilitators, and Solutions to Optimal Patient Portal and Personal Health Record Use: A Systematic Review of the Literature.

AMIA Annu Symp Proc 2017 16;2017:1913-1922. Epub 2018 Apr 16.

Department of Biomedical Informatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA.

Patient portal and personal health record adoption and usage rates have been suboptimal. A systematic review of the literature was performed to capture all published studies that specifically addressed barriers, facilitators, and solutions to optimal patient portal and personal health record enrollment and use. Consistent themes emerged from the review. Patient attitudes were critical as either barrier or facilitator. Institutional buy-in, information technology support, and aggressive tailored marketing were important facilitators. Interface redesign was a popular solution. Quantitative studies identified many barriers to optimal patient portal and personal health record enrollment and use, and qualitative and mixed methods research revealed thoughtful explanations for why they existed. Our study demonstrated the value of qualitative and mixed research methodologies in understanding the adoption of consumer health technologies. Results from the systematic review should be used to guide the design and implementation of future patient portals and personal health records, and ultimately, close the digital divide.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5977619PMC
March 2019

Improving the value of care for appendectomy through an individual surgeon-specific approach.

J Pediatr Surg 2018 Jun 8;53(6):1181-1186. Epub 2018 Mar 8.

Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN.

Purpose: Standardized care via a unified surgeon preference card for pediatric appendectomy can result in significant cost reduction. The purpose of this study was to evaluate the impact of cost and outcome feedback to surgeons on value of care in an environment reluctant to adopt a standardized surgeon preference card.

Methods: Prospective observational study comparing operating room (OR) supply costs and patient outcomes for appendectomy in children with 6-month observation periods both before and after intervention. The intervention was real-time feedback of OR supply cost data to individual surgeons via automated dashboards and monthly reports.

Results: Two hundred sixteen children underwent laparoscopic appendectomy for non-perforated appendicitis (110 pre-intervention and 106 post-intervention). Median supply cost significantly decreased after intervention: $884 (IQR $705-$1025) to $388 (IQR $182-$776), p<0.001. No significant change was detected in median OR duration (47min [IQR 36-63] to 50min [IQR 38-64], p=0.520) or adverse events (1 [0.9%] to 6 [4.7%], p=0.062). OR supply costs for individual surgeons significantly decreased during the intervention period for 6 of 8 surgeons (87.5%).

Conclusion: Approaching value measurement with a surgeon-specific (rather than group-wide) approach can reduce OR supply costs while maintaining excellent clinical outcomes.

Level Of Evidence: Level II.
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http://dx.doi.org/10.1016/j.jpedsurg.2018.02.081DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5994354PMC
June 2018

A technology-based patient and family engagement consult service for the pediatric hospital setting.

J Am Med Inform Assoc 2018 02;25(2):167-174

Department of Biomedical Informatics, VUMC, Nashville, TN, USA.

Objective: The Vanderbilt Children's Hospital launched an innovative Technology-Based Patient and Family Engagement Consult Service in 2014. This paper describes our initial experience with this service, characterizes health-related needs of families of hospitalized children, and details the technologies recommended to promote engagement and meet needs.

Materials And Methods: We retrospectively reviewed consult service documentation for patient characteristics, health-related needs, and consultation team recommendations. Needs were categorized using a consumer health needs taxonomy. Recommendations were classified by technology type.

Results: Twenty-two consultations were conducted with families of patients ranging in age from newborn to 15 years, most with new diagnoses or chronic illnesses. The consultation team identified 99 health-related needs (4.5 per consultation) and made 166 recommendations (7.5 per consultation, 1.7 per need). Need categories included 38 informational needs, 26 medical needs, 23 logistical needs, and 12 social needs. The most common recommendations were websites (50, 30%) and mobile applications (30, 18%). The most frequent recommendations by need category were websites for informational needs (39, 50%), mobile applications for medical needs (15, 40%), patient portals for logistical needs (12, 44%), and disease-specific support groups for social needs (19, 56%).

Discussion: Families of hospitalized pediatric patients have a variety of health-related needs, many of which could be addressed by technology recommendations from an engagement consult service.

Conclusion: This service is the first of its kind, offering a potentially generalizable and scalable approach to assessing health-related needs, meeting them with technologies, and promoting patient and family engagement in the inpatient setting.
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http://dx.doi.org/10.1093/jamia/ocx067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6080811PMC
February 2018

Long-term Patterns of Patient Portal Use for Pediatric Patients at an Academic Medical Center.

Appl Clin Inform 2017 Aug 2;8(3):779-793. Epub 2017 Aug 2.

Bryan Steitz, 2525 West End Avenue, Suite 1475, Nashville, TN 37203, Tel. (502) 320-6797, Email:

Background: Patient portal adoption has increased over the last two decades. Most research about patient portals has focused on adult populations in the primary care and medical specialty settings.

Objective: We describe initial and long-term portal use by pediatric patients and their caregivers in a broadly deployed patient portal at an academic medical center.

Methods: We analyzed portal usage for pediatric patients and their caregivers from 2008 to 2014. We recorded usage events with time stamps; user role defined as self, surrogate (i.e., parent or guardian), or delegate; and functions accessed. Usage events were grouped into sessions to calculate descriptive statistics by patient age, user role, and active use over time.

Results: From 2008 to 2014, the number of portal accounts increased from 633 to 17,128. 15.9% of pediatric patients had their own account; 93.6%, a surrogate account; and 2.2% a delegate account. During the study period, 15,711 unique users initiated 493,753 sessions and accessed 1,491,237 functions. Most commonly used functions were secure messaging (accessed in 309,204 sessions; 62.6%); test results (174,239; 35.3%) and appointments (104,830; 21.2%). Function usage was greatest for patients ages 0-2 years (136,245 functions accessed; 23.1%) and 15-17 years (109,241;18.5%). Surrogate users conducted 83.2% of logins for adolescent patients. Portal accounts were actively used for < 1 year for 9,551 patients (55.8%), 1-2 years for 2,826 patients (16.5%), 2-3 years for 1,968 patients (11.5%) and over 3 years for 2,783 patients (16.3%).

Conclusion: Pediatric patients and caregivers have avidly used messaging, test result, and appointment functions. The majority of access was done by surrogates. Adolescent portal usage increased with age. Most accounts for pediatric patients were only used actively for a few years, with peak usage for patients in early childhood and late adolescence.
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http://dx.doi.org/10.4338/ACI-2017-01-RA-0005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6220688PMC
August 2017

Complexity of medical decision-making in care provided by surgeons through patient portals.

J Surg Res 2017 06 8;214:93-101. Epub 2017 Mar 8.

Department of Pediatric Surgery, Vanderbilt Children's Medical Center, Nashville, Tennessee; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Pediatrics, Vanderbilt Children's Medical Center, Nashville, Tennessee.

Background: Patient portals are online applications that allow patients to interact with healthcare organizations and view information. Portal messages exchanged between patients and providers contain diverse types of communications, including delivery of medical care. The types of communications and complexity of medical decision-making in portal messages sent to surgeons have not been studied.

Materials And Methods: We obtained all message threads initiated by patients and exchanged with surgical providers through the Vanderbilt University Medical Center patient portal from June 1 to December 31, 2014. Five hundred randomly selected messages were manually analyzed by two research team members to determine the types of communication (i.e., informational, medical, logistical, or social), whether medical care was delivered, and complexity of medical decision-making as defined for outpatient billing in each message thread.

Results: A total of 9408 message threads were sent to 401 surgical providers during the study period. In the 500 threads selected for detailed analysis, 1293 distinct issues were communicated, with an average of 2.6 issues per thread. Medical needs were communicated in 453 message threads (90.6%). Further, 339 message threads (67.8%) contained medical decision-making. Overall complexity of medical decision-making was straightforward in 210 messages (62%), low in 102 messages (30%), and moderate in 27 messages (8%). No highly complex decisions were made over portal messaging.

Conclusions: Through patient portal messages, surgeons deliver substantial medical care with varied levels of medical complexity. Models for compensation of online care must be developed as consumer and surgeon adoption of these technologies increases.
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http://dx.doi.org/10.1016/j.jss.2017.02.077DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5474935PMC
June 2017

Use of a Patient Portal During Hospital Admissions to Surgical Services.

AMIA Annu Symp Proc 2016 10;2016:1967-1976. Epub 2017 Feb 10.

Vanderbilt University Medical Center, Nashville, TN.

Patient portal research has focused on medical outpatient settings, with little known about portal use during hospitalizations or by surgical patients. We measured portal adoption among patients admitted to surgical services over two years. Surgical services managed 37,025 admissions of 31,310 unique patients. One-fourth of admissions (9,362, 25.3%) involved patients registered for the portal. Registration rates were highest for admissions to laparoscopic/gastrointestinal (55%) and oncology/endocrine (50%) services. Portal use occurred during 1,486 surgical admissions, 4% of all and 16% of those registered at admission. Inpatient portal use was associated with patients who were white, male, and had longer lengths of stay (p < 0.01). Viewing health record data and secure messaging were the most commonly used functions, accessed in 4,836 (72.9%) and 1,626 (24.5%) user sessions. Without specific encouragement, hospitalized surgical patients are using our patient portal. The surgical inpatient setting may provide opportunities for patient engagement using patient portals.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5333326PMC
September 2017

Adoption of Secure Messaging in a Patient Portal across Pediatric Specialties.

AMIA Annu Symp Proc 2016 10;2016:1930-1939. Epub 2017 Feb 10.

Vanderbilt University Medical Center, Nashville, TN.

Few studies have explored adoption of patient portals for pediatric patients outside primary care or disease-specific applications. We examined use of patient-provider messaging in a patient portal across pediatric specialties during the three years after implementation of pediatric portal accounts at Vanderbilt University Medical Center. We determined the number of patient-initiated message threads and clinic visits for pediatric specialties and percentage of these outpatient interactions (i.e., message threads + clinic visits) done through messaging. Generalized estimating equations measured the likelihood of message-based interaction. During the study period, pediatric families initiated 33,503 messages and participated in 318,386 clinic visits. The number of messages sent (and messaging percentage of outpatient interaction) increased each year from 2,860 (2.7%) to 18,772 (17%). Primary care received 4,368 messages (3.4% of outpatient interactions); pediatric subspecialties, 29,135 (13.0%). Rapid growth in messaging volume over time was seen in primary care and most pediatric specialties (OR>1.0; p<0.05).
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5333207PMC
September 2017

Review of information technology for surgical patient care.

J Surg Res 2016 06 29;203(1):121-39. Epub 2016 Mar 29.

Department of Pediatric Surgery, Vanderbilt Children's Medical Center, Nashville, Tennessee; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee.

Background: Electronic health records (EHRs), computerized provider order entry (CPOE), and patient portals have experienced increased adoption by health care systems. The objective of this study was to review evidence regarding the impact of such health information technologies (HIT) on surgical practice.

Materials And Methods: A search of Medline, EMBASE, CINAHL, and the Cochrane Library was performed to identify data-driven, nonsurvey studies about the effects of HIT on surgical care. Domain experts were queried for relevant articles. Two authors independently reviewed abstracts for inclusion criteria and analyzed full text of eligible articles.

Results: A total of 2890 citations were identified. Of them, 32 observational studies and two randomized controlled trials met eligibility criteria. EHR or CPOE improved appropriate antibiotic administration for surgical procedures in 13 comparative observational studies. Five comparative observational studies indicated that electronically generated operative notes had increased accuracy, completeness, and availability in the medical record. The Internet as an information resource about surgical procedures was generally inadequate. Surgical patients and providers demonstrated rapid adoption of patient portals, with increasing proportions of online versus inperson outpatient surgical encounters.

Conclusions: The overall quality of evidence about the effects of HIT in surgical practice was low. Current data suggest an improvement in appropriate perioperative antibiotic administration and accuracy of operative reports from CPOE and EHR applications. Online consumer health educational resources and patient portals are popular among patients and families, but their impact has not been studied well in surgical populations. With increasing adoption of HIT, further research is needed to optimize the efficacy of such tools in surgical care.
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http://dx.doi.org/10.1016/j.jss.2016.03.053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4939767PMC
June 2016

Fundamental Use of Surgical Energy (FUSE) certification: validation and predictors of success.

Surg Endosc 2016 Mar 15;30(3):916-24. Epub 2015 Aug 15.

Department of Surgery, Harvard University, Boston, MA, USA.

Introduction: The Fundamental Use of Surgical Energy (FUSE) program includes a Web-based didactic curriculum and a high-stakes multiple-choice question examination with the goal to provide certification of knowledge on the safe use of surgical energy-based devices. The purpose of this study was (1) to set a passing score through a psychometrically sound process and (2) to determine what pretest factors predicted passing the FUSE examination.

Methods: Beta-testing of multiple-choice questions on 62 topics of importance to the safe use of surgical energy-based devices was performed. Eligible test takers were physicians with a minimum of 1 year of surgical training who were recruited by FUSE task force members. A pretest survey collected baseline information.

Results: A total of 227 individuals completed the FUSE beta-test, and 208 completed the pretest survey. The passing/cut score for the first test form of the FUSE multiple-choice examination was determined using the modified Angoff methodology and for the second test form was determined using a linear equating methodology. The overall passing rate across the two examination forms was 81.5%. Self-reported time studying the FUSE Web-based curriculum for a minimum of >2 h was associated with a passing examination score (p < 0.001). Performance was not different based on increased years of surgical practice (p = 0.363), self-reported expertise on one or more types of energy-based devices (p = 0.683), participation in the FUSE postgraduate course (p = 0.426), or having reviewed the FUSE manual (p = 0.428). Logistic regression found that studying the FUSE didactics for >2 h predicted a passing score (OR 3.61; 95% CI 1.44-9.05; p = 0.006) independent of the other baseline characteristics recorded.

Conclusion(s): The development of the FUSE examination, including the passing score, followed a psychometrically sound process. Self-reported time studying the FUSE curriculum predicted a passing score independent of other pretest characteristics such as years in practice and self-reported expertise.
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http://dx.doi.org/10.1007/s00464-015-4334-3DOI Listing
March 2016
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