A Multipopulation Multiobjective Ant Colony System Considering Travel and Prevention Costs for Vehicle Routing in COVID-19-Like Epidemics

As transportation system plays a vastly important role in combatting newly-emerging and severe epidemics like the coronavirus disease 2019 (COVID-19), the vehicle routing problem (VRP) in epidemics has become an emerging topic that has attracted increasing attention worldwide. However, most existing VRP models are not suitable for epidemic situations, because they do not consider the prevention cost caused by issues such as viral tests and quarantine during the traveling. Therefore, this paper proposes a multi-objective VRP model for epidemic situations, named VRP4E, which considers not only the traditional travel cost but also the prevention cost of the VRP in epidemic situations. To efficiently solve the VRP4E, this paper further proposes a novel algorithm named multi-objective ant colony system algorithm for epidemic situations, termed MOACS4E, together with three novel designs. First, by extending the efficient “multiple populations for multiple objectives” framework, the MOACS4E adopts two ant colonies to optimize the travel and prevention costs respectively, so as to improve the search efficiency. Second, a pheromone fusion-based solution generation method is proposed to fuse the pheromones from different colonies to increase solution diversity effectively. Third, a solution quality improvement method is further proposed to improve the solutions for the prevention cost objective. The effectiveness of the MOACS4E is verified in experiments on 25 generated benchmarks by comparison with six state-of-the-art and modern algorithms. Moreover, the VRP4E in different epidemic situations and a real-world case in the Beijing-Tianjin-Hebei region, China, are further studied to provide helpful insights for combatting COVID-19-like epidemics.

Virtual Sprint Outpatient Electronic Health Record Training and Optimization Effect on Provider Burnout.

OBJECTIVES: This study aimed to develop a virtual electronic health record (EHR) training and optimization program and evaluate the impact of the virtual model on provider and staff burnout and electronic health record (EHR) experience. METHODS: UCHealth created and supported a multidisciplinary EHR optimization and training program, known as the Epic Sprint Program. The Sprint Team conducted dozens of onsite Sprint events over the course of several years prior to the pandemic but transitioned to a fully virtual program and successfully "sprinted" 21 outpatient clinics from May to December 2020. Core program components of group and 1:1 training, workflow analysis, and new or adjusted EHR build were unchanged from the onsite model. Pre- and post-Sprint surveys provided detailed, objective data about EHR usability, EHR proficiency, job satisfaction, and burnout. RESULTS: The EHR Net Promoter Score (NPS), a likelihood to recommend metric, increased by 39 points (-3 pre and 36 post; p < 0.001) for providers and 29 points (8 pre and 37 post; p = 0.001) for staff post-Sprint. Positive provider (NPS = +53) and staff (NPS = +47) NPS scores indicated a high likelihood to recommend the Sprint Program. Post-Sprint surveys also reflect an increase in providers (10%; p = 0.04) and staff (9%; 0.13) who indicated "no burnout" or "did not feel burned out." DISCUSSION: The UCHealth Sprint Team transitioned this comprehensive, enterprise level initiative from an onsite model to a fully virtual EHR training and optimization program during the first few months of the novel coronavirus disease (COVID-19) pandemic. Despite this change in program delivery, survey data clearly demonstrated improved EHR satisfaction, a high likelihood to recommend a sprint to a friend or colleague, and a trend toward burnout reduction in providers and staff. CONCLUSION: Changing an existing on-site EHR optimization program to a purely virtual format can be successful, and this study showed improved provider and staff EHR satisfaction with reduced burnout.

Patients Contributing to Visit Notes: Mixed Methods Evaluation of OurNotes.

BACKGROUND: Secure patient portals are widely available, and patients use them to view their electronic health records, including their clinical notes. We conducted experiments asking them to cogenerate notes with their clinicians, an intervention called OurNotes. OBJECTIVE: This study aims to assess patient and provider experiences and attitudes after 12 months of a pilot intervention. METHODS: Before scheduled primary care visits, patients were asked to submit a word-constrained, unstructured interval history and an agenda for what they would like to discuss at the visit. Using site-specific methods, their providers were invited to incorporate the submissions into notes documenting the visits. Sites served urban, suburban, and rural patients in primary care practices in 4 academic health centers in Boston (Massachusetts), Lebanon (New Hampshire), Denver (Colorado), and Seattle (Washington). Each practice offered electronic access to visit notes (open notes) to its patients for several years. A mixed methods evaluation used tracking data and electronic survey responses from patients and clinicians. Participants were 174 providers and 1962 patients who submitted at least 1 previsit form. We asked providers about the usefulness of the submissions, effects on workflow, and ideas for the future. We asked patients about difficulties and benefits of providing the requested information and ideas for future improvements. RESULTS: Forms were submitted before 9.15% (5365/58,652) eligible visits, and 43.7% (76/174) providers and 26.76% (525/1962) patients responded to the postintervention evaluation surveys; 74 providers and 321 patients remembered receiving and completing the forms and answered the survey questions. Most clinicians thought interim patient histories (69/74, 93%) and patient agendas (72/74, 97%) as good ideas, 70% (52/74) usually or always incorporated them into visit notes, 54% (40/74) reported no change in visit length, and 35% (26/74) thought they saved time. Their most common suggestions related to improving notifications when patient forms were received, making it easier to find the form and insert it into the note, and educating patients about how best to prepare their submissions. Patient respondents were generally well educated, most found the history (259/321, 80.7%) and agenda (286/321, 89.1%) questions not difficult to answer; more than 92.2% (296/321) thought sending answers before the visit a good idea; 68.8% (221/321) thought the questions helped them prepare for the visit. Common suggestions by patients included learning to write better answers and wanting to know that their submissions were read by their clinicians. At the end of the pilot, all participating providers chose to continue the OurNotes previsit form, and sites considered expanding the intervention to more clinicians and adapting it for telemedicine visits. CONCLUSIONS: OurNotes interests patients, and providers experience it as a positive intervention. Participation by patients, care partners, clinicians, and electronic health record experts will facilitate further development.

The potential role of abnormal angiotensin-converting enzyme 2 expression correlated with immune infiltration after SARS-CoV-2 infection in the prognosis of breast cancer.

The potential role of abnormal ACE2 expression after SARS-CoV-2 infection in the prognosis of breast cancer is still ambiguous. In this study, we analyzed ACE2 changes in breast cancer and studied the correlation between ACE2 and the prognosis and further analyzed the relationship between immune infiltration and the prognosis of different breast cancer subtypes. Finally, we inferred the prognosis of breast cancer patients after SARS-CoV-2 infection. We found that ACE2 expression decreased significantly in breast cancer, except for basal-like subtype. Decreased ACE2 expression level was correlated with abnormal immune infiltration and poorer prognosis of luminal B breast cancer (RFS: HR 0.76, 95%CI=0.63-0.92, p=0.005; DMFS: HR 0.70, 95%CI=0.49-1.00, p=0.046). The expression of ACE2 was strongly positively correlated with the immune infiltration level of CD8+ T cell (r=0.184, p<0.001), CD4+ T cell (r=0.104, p=0.02) and neutrophils (r=0.101, p=0.02). ACE2 expression level in the luminal subtype was positively correlated with CD8A and CD8B markers in CD8+ T cells, and CEACAM3, S100A12 in neutrophils. In conclusion, breast tumor tissues might undergo a further decrease in the expression level of ACE2 after SARS-CoV-2 infection, which could contribute to further deterioration of immune infiltration and worsen the prognosis of luminal B breast cancer after SARS-CoV-2 infection.

Mediators of SARS-CoV-2 entry are preferentially enriched in cardiomyocytes.

BACKGROUND: The coronavirus disease 2019 (COVID-19) has spread rapidly around the world. In addition to common respiratory symptoms such as cough and fever, some patients also have cardiac injury, however, the mechanism of cardiac injury is not clear. In this study, we analyzed the RNA expression atlases of angiotensin-converting enzyme 2(ACE2), cathepsin B (CTSB) and cathepsin L (CTSL) in the human embryonic heart at single-cell resolution. RESULTS: The results showed that ACE2 was preferentially enriched in cardiomyocytes. Interestingly, serine protease transmembrane serine protease 2 (TMPRSS2) had less expression in cardiomyocytes, but CTSB and CTSL, which belonged to cell protease, could be found to be enriched in cardiomyocytes. The results of enrichment analysis showed that differentially expressed genes (DEGs) in ACE2-positive cardiomyocytes were mainly enriched in the processes of cardiac muscle contraction, regulation of cardiac conduction, mitochondrial respiratory chain, ion channel binding, adrenergic signaling in cardiomyocytes and viral transcription. CONCLUSIONS: Our study suggests that both atrial and ventricular cardiomyocytes are potentially susceptible to severe acute respiratory syndrome coronavirus-2(SARS-CoV-2), and SARS-CoV-2 may enter ventricular cardiomyocytes using CTSB/CTSL for S protein priming. This may be the partial cellular mechanism of cardiac injury in patients with COVID-19.

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.

Advance Care Planning Among Users of a Patient Portal During the COVID-19 Pandemic: Retrospective Observational Study.

BACKGROUND: Advance care planning is the process of discussing health care treatment preferences based on patients' personal values, and it often involves the completion of advance directives. In the first months of 2020, a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), began circulating widely in the American state of Colorado, leading to widespread diagnosis of coronavirus disease (COVID-19), hospitalizations, and deaths. In this context, the importance of technology-based, non-face-to-face methods to conduct advance care planning via patient portals has increased. OBJECTIVE: The aim of this study was to determine the rates of use of a web-based advance care planning tool through a health system-based electronic patient portal both before and in the early months of the COVID-19 pandemic. METHODS: In 2017, we implemented web-based tools through the patient portal of UCHealth's electronic health record (EHR) for patients to learn about advance care planning and complete an electronically signed medical durable power of attorney (MDPOA) to legally appoint a medical decision maker. Patients accessing the portal can complete and submit a legally valid MDPOA, which becomes part of their medical record. We collected data on the patients' date of MDPOA completion, use of advance care planning messaging, age, sex, and geographic location during the early phase of the COVID-19 pandemic (December 29, 2019, to May 30, 2020). RESULTS: Over a 5-month period that includes the early phase of the COVID-19 pandemic in Colorado, total monthly use of the advance care planning portal tool increased from 418 users in January to 1037 users in April and then decreased slightly to 815 users in May. The number of MDPOA forms submitted per week increased 2.4-fold after the stay-at-home order was issued in Colorado on March 26, 2020 (P<.001). The mean age of the advance care planning portal users was 47.7 years (SD 16.1), and 2206/3292 (67.0%) were female. Women were more likely than men to complete an MDPOA, particularly in younger age groups (P<.001). The primary use of the advance care planning portal tools was the completion of an MDPOA (3138/3292, 95.3%), compared to sending an electronic message (148/3292, 4.5%). Over 50% of patients who completed an MDPOA did not have a prior agent in the EHR. CONCLUSIONS: Use of a web-based patient portal to complete an MDPOA increased substantially during the first months of the COVID-19 pandemic in Colorado. There was an increase in advance care planning that corresponded with state government shelter-in-place orders as well as public health reports of increased numbers of COVID-19 cases and deaths. Patient portals are an important tool for providing advance care planning resources and documenting medical decision makers during the pandemic to ensure that medical treatment aligns with patient goals and values.

Clinical informatics accelerates health system adaptation to the COVID-19 pandemic: examples from Colorado.

OBJECTIVE: Large health systems responding to the coronavirus disease 2019 (COVID-19) pandemic face a broad range of challenges; we describe 14 examples of innovative and effective informatics interventions. MATERIALS AND METHODS: A team of 30 physician and 17 nurse informaticists with an electronic health record (EHR) and associated informatics tools. RESULTS: To meet the demands posed by the influx of patients with COVID-19 into the health system, the team built solutions to accomplish the following goals: 1) train physicians and nurses quickly to manage a potential surge of hospital patients; 2) build and adjust interactive visual pathways to guide decisions; 3) scale up video visits and teach best-practice communication; 4) use tablets and remote monitors to improve in-hospital and posthospital patient connections; 5) allow hundreds of physicians to build rapid consensus; 6) improve the use of advance care planning; 7) keep clinicians aware of patients' changing COVID-19 status; 8) connect nurses and families in new ways; 9) semi-automate Crisis Standards of Care; and 10) predict future hospitalizations. DISCUSSION: During the onset of the COVID-19 pandemic, the UCHealth Joint Informatics Group applied a strategy of "practical informatics" to rapidly translate critical leadership decisions into understandable guidance and effective tools for patient care. CONCLUSION: Informatics-trained physicians and nurses drew upon their trusted relationships with multiple teams within the organization to create practical solutions for onboarding, clinical decision-making, telehealth, and predictive analytics.