OBJECTIVE: We sought to develop and evaluate an electronic health record (EHR) genetic testing tracking system to address the barriers and limitations of existing spreadsheet-based workarounds.

MATERIALS AND METHODS: We evaluated the spreadsheet-based system using mixed effects logistic regression to identify factors associated with delayed follow up. These factors informed the design of an EHR-integrated genetic testing tracking system. After deployment, we assessed the system in 2 ways. We analyzed EHR access logs and note data to assess patient outcomes and performed semistructured interviews with users to identify impact of the system on work.

RESULTS: We found that patient-reported race was a significant predictor of documented genetic testing follow up, indicating a possible inequity in care. We implemented a CDS system including a patient data capture form and management dashboard to facilitate important care tasks. The system significantly sped review of results and significantly increased documentation of follow-up recommendations. Interviews with key system users identified a range of sociotechnical factors (ie, tools, tasks, collaboration) that contribute to safer and more efficient care.

DISCUSSION: Our new tracking system ended decades of workarounds for identifying and communicating test results and improved clinical workflows. Interview participants related that the system decreased cognitive and time burden which allowed them to focus on direct patient interaction.

CONCLUSION: By assembling a multidisciplinary team, we designed a novel patient tracking system that improves genetic testing follow up. Similar approaches may be effective in other clinical settings.

OBJECTIVE: State agencies have developed reporting systems of safety events that include events related to health information technology (HIT). These data come from hospital reporting systems where staff submit safety reports and nurses, in the role of safety managers, review, and code events. Safety managers may have varying degrees of experience with identifying events related to HIT. Our objective was to review events potentially involving HIT and compare those with what was reported to the state.

METHODS: We performed a structured review of 1 year of safety events from an academic pediatric healthcare system. We reviewed the free-text description of each event and applied a classification scheme derived from the AHRQ Health IT Hazard Manager and compared the results with events reported to the state as involving HIT.

RESULTS: Of 33,218 safety events for a 1-year period, 1247 included key words related to HIT and/or were indicated by safety managers as involving HIT. Of the 1247 events, the structured review identified 769 as involving HIT. In comparison, safety managers only identified 194 of the 769 events (25%) as involving HIT. Most events, 353 (46%), not identified by safety managers were documentation issues. Of the 1247 events, the structured review identified 478 as not involving HIT while safety managers identified and reported 81 of these 478 events (17%) as involving HIT.

CONCLUSIONS: The current process of reporting safety events lacks standardization in identifying health technology contributions to safety events, which may minimize the effectiveness of safety initiatives.

OBJECTIVE: We sought to develop and evaluate an electronic health record (EHR) genetic testing tracking system to address the barriers and limitations of existing spreadsheet-based workarounds.

MATERIALS AND METHODS: We evaluated the spreadsheet-based system using mixed effects logistic regression to identify factors associated with delayed follow up. These factors informed the design of an EHR-integrated genetic testing tracking system. After deployment, we assessed the system in 2 ways. We analyzed EHR access logs and note data to assess patient outcomes and performed semistructured interviews with users to identify impact of the system on work.

RESULTS: We found that patient-reported race was a significant predictor of documented genetic testing follow up, indicating a possible inequity in care. We implemented a CDS system including a patient data capture form and management dashboard to facilitate important care tasks. The system significantly sped review of results and significantly increased documentation of follow-up recommendations. Interviews with key system users identified a range of sociotechnical factors (ie, tools, tasks, collaboration) that contribute to safer and more efficient care.

DISCUSSION: Our new tracking system ended decades of workarounds for identifying and communicating test results and improved clinical workflows. Interview participants related that the system decreased cognitive and time burden which allowed them to focus on direct patient interaction.

CONCLUSION: By assembling a multidisciplinary team, we designed a novel patient tracking system that improves genetic testing follow up. Similar approaches may be effective in other clinical settings.

OBJECTIVES:  Clinical decision support (CDS) has promise for the implementation of antimicrobial stewardship programs (ASPs) in the emergency department (ED). We sought to assess the usability of a newly developed automated CDS to improve guideline-adherent antibiotic prescribing for pediatric community-acquired pneumonia (CAP) and urinary tract infection (UTI).

METHODS:  We conducted comparative usability testing between an automated, prototype CDS-enhanced discharge order set and standard order set, for pediatric CAP and UTI antibiotic prescribing. After an extensive user-centered design process, the prototype CDS was integrated into the electronic health record, used passive activation, and embedded locally adapted prescribing guidelines. Participants were randomized to interact with three simulated ED scenarios of children with CAP or UTI, across both systems. Measures included task completion, decision-making and usability errors, clinical actions (order set use and correct antibiotic selection), as well as objective measures of system usability, utility, and workload using the National Aeronautics and Space Administration Task Load Index (NASA-TLX). The prototype CDS was iteratively refined to optimize usability and workflow.

RESULTS:  Usability testing in 21 ED clinical providers demonstrated that, compared to the standard order sets, providers preferred the prototype CDS, with improvements in domains such as explanations of suggested antibiotic choices ( < 0.001) and provision of additional resources on antibiotic prescription ( < 0.001). Simulated use of the CDS also led to overall improved guideline-adherent prescribing, with a 31% improvement for CAP. A trend was present toward absolute workload reduction. Using the NASA-TLX, workload scores for the current system were median 26, interquartile ranges (IQR): 11 to 41 versus median 25, and IQR: 10.5 to 39.5 for the CDS system ( = 0.117).

CONCLUSION:  Our CDS-enhanced discharge order set for ED antibiotic prescribing was strongly preferred by users, improved the accuracy of antibiotic prescribing, and trended toward reduced provider workload. The CDS was optimized for impact on guideline-adherent antibiotic prescribing from the ED and end-user acceptability to support future evaluative trials of ED ASPs.

<p><strong>OBJECTIVES: </strong>To assess the current landscape of clinical decision support (CDS) tools in PICUs in order to identify priority areas of focus in this field.</p>

<p><strong>DESIGN: </strong>International, quantitative, cross-sectional survey.</p>

<p><strong>SETTING: </strong>Role-specific, web-based survey administered in November and December 2020.</p>

<p><strong>SUBJECTS: </strong>Medical directors, bedside nurses, attending physicians, and residents/advanced practice providers at Pediatric Acute Lung Injury and Sepsis Network-affiliated PICUs.</p>

<p><strong>INTERVENTIONS: </strong>None.</p>

<p><strong>MEASUREMENTS AND MAIN RESULTS: </strong>The survey was completed by 109 respondents from 45 institutions, primarily attending physicians from university-affiliated PICUs in the United States. The most commonly used CDS tools were people-based resources (93% used always or most of the time) and laboratory result highlighting (86%), with order sets, order-based alerts, and other electronic CDS tools also used frequently. The most important goal providers endorsed for CDS tools were a proven impact on patient safety and an evidence base for their use. Negative perceptions of CDS included concerns about diminished critical thinking and the burden of intrusive processes on providers. Routine assessment of existing CDS was rare, with infrequent reported use of observation to assess CDS impact on workflows or measures of individual alert burden.</p>

<p><strong>CONCLUSIONS: </strong>Although providers share some consensus over CDS utility, we identified specific priority areas of research focus. Consensus across practitioners exists around the importance of evidence-based CDS tools having a proven impact on patient safety. Despite broad presence of CDS tools in PICUs, practitioners continue to view them as intrusive and with concern for diminished critical thinking. Deimplementing ineffective CDS may mitigate this burden, though postimplementation evaluation of CDS is rare.</p>

<p><strong>BACKGROUND: </strong> Surveillance for surgical site infections (SSIs) after ambulatory surgery in children requires a detailed manual chart review to assess criteria defined by the National Health and Safety Network (NHSN). Electronic health records (EHRs) impose an inefficient search process where infection preventionists must manually review every postsurgical encounter (&lt; 30 days). Using text mining and business intelligence software, we developed an information foraging application, the SSI Workbench, to visually present which postsurgical encounters included SSI-related terms and synonyms, antibiotic, and culture orders.</p>

<p><strong>OBJECTIVE: </strong> This article compares the Workbench and EHR on four dimensions: (1) effectiveness, (2) efficiency, (3) workload, and (4) usability.</p>

<p><strong>METHODS: </strong> Comparative usability test of Workbench and EHR. Objective test metrics are time per case, encounters reviewed per case, time per encounter, and retrieval of information meeting NHSN definitions. Subjective measures are cognitive load using the National Aeronautics and Space Administration (NASA) Task Load Index (NASA TLX), and a questionnaire on system usability and utility.</p>

<p><strong>RESULTS: </strong> Eight infection preventionists participated in the test. There was no difference in effectiveness as subjects retrieved information from all cases, using both systems, to meet the NHSN criteria. There was no difference in efficiency in time per case between the Workbench and EHR (8.58 vs. 7.39 minutes,  = 0.36). However, with the Workbench subjects opened fewer encounters per case (3.0 vs. 7.5,  = 0.002), spent more time per encounter (2.23 vs. 0.92 minutes,  = 0.002), rated the Workbench lower in cognitive load (NASA TLX, 24 vs. 33,  = 0.02), and significantly higher in measures of usability.</p>

<p><strong>CONCLUSION: </strong> Compared with the EHR, the Workbench was more usable, short, and reduced cognitive load. In overall efficiency, the Workbench did not save time, but demonstrated a shift from between-encounter foraging to within-encounter foraging and was rated as significantly more efficient. Our results suggest that infection surveillance can be better supported by systems applying information foraging theory.</p>

<p><strong>Objective: </strong>The objective was to prospectively derive and validate a prediction rule for detecting cases warranting investigation for surgical site infections (SSI) after ambulatory surgery.</p>

<p><strong>Methods: </strong>We analysed electronic health record (EHR) data for children who underwent ambulatory surgery at one of 4 ambulatory surgical facilities. Using regularized logistic regression and random forests, we derived SSI prediction rules using 30 months of data (derivation set) and evaluated performance with data from the subsequent 10 months (validation set). Models were developed both with and without data extracted from free text. We also evaluated the presence of an antibiotic prescription within 60 days after surgery as an independent indicator of SSI evidence. Our goal was to exceed 80% sensitivity and 10% positive predictive value (PPV).</p>

<p><strong>Results: </strong>We identified 234 surgeries with evidence of SSI among the 7910 surgeries available for analysis. We derived and validated an optimal prediction rule that included free text data using a random forest model (sensitivity = 0.9, PPV = 0.28). Presence of an antibiotic prescription had poor sensitivity (0.65) when applied to the derivation data but performed better when applied to the validation data (sensitivity = 0.84, PPV = 0.28).</p>

<p><strong>Conclusions: </strong>EHR data can facilitate SSI surveillance with adequate sensitivity and PPV.</p>

<p>Clinical genome and exome sequencing can diagnose pediatric patients with complex conditions that often require follow-up care with multiple specialties. The American Academy of Pediatrics emphasizes the role of the medical home and the primary care pediatrician in coordinating care for patients who need multidisciplinary support. In addition, the electronic health record (EHR) with embedded clinical decision support is recognized as an important component in providing care in this setting. We interviewed 6 clinicians to assess their experience caring for patients with complex and rare genetic findings and hear their opinions about how the EHR currently supports this role. Using these results, we designed a candidate EHR clinical decision support application mock-up and conducted formative exploratory user testing with 26 pediatric primary care providers to capture opinions on its utility in practice with respect to a specific clinical scenario. Our results indicate agreement that the functionality represented by the mock-up would effectively assist with care and warrants further development.</p>

<p><strong>OBJECTIVE: </strong>To describe the use of digital images captured by parents or guardians and sent to clinicians for assessment of wounds after pediatric ambulatory surgery.</p>

<p><strong>METHODS: </strong>Subjects with digital images of post-operative wounds were identified as part of an on-going cohort study of infections after ambulatory surgery within a large pediatric healthcare system. We performed a structured review of the electronic health record (EHR) to determine how digital images were documented in the EHR and used in clinical care.</p>

<p><strong>RESULTS: </strong>We identified 166 patients whose parent or guardian reported sending a digital image of the wound to the clinician after surgery. A corresponding digital image was located in the EHR in only 121 of these encounters. A change in clinical management was documented in 20% of these encounters, including referral for in-person evaluation of the wound and antibiotic prescription.</p>

<p><strong>CONCLUSION: </strong>Clinical teams have developed ad hoc workflows to use digital images to evaluate post-operative pediatric surgical patients. Because the use of digital images to support follow-up care after ambulatory surgery is likely to increase, it is important that high-quality images are captured and documented appropriately in the EHR to ensure privacy, security, and a high-level of care.</p>

<p>We describe the user-centered development of an electronic medical record-based portal, "MyAsthma," designed to facilitate shared decision making in pediatric asthma. Interviews and focus groups with 7 parents of children with asthma and 51 clinical team members elicited 2 overarching requirements: that the portal should support sustained communication and ensure patient safety. Parents and clinicians prioritized features including collecting parent and child concerns and goals; symptom, side effect, and medication adherence tracking with decision support; and accessible educational materials. Iterative usability testing refined the system. MyAsthma provides a model for using technology to foster shared decision making in ambulatory care settings.</p>