Off-brand: A 6-year study of medication brand and generic name usage in a multifacility academic healthcare system.

BACKGROUND: Usage of medication brand names in electronic health records may introduce conflicts of interest, perpetuate false perceptions of brand superiority, alter prescribing practices, and cause confusion leading to errors. OBJECTIVE: We sought to identify the frequency of brand name medication usage in clinical documentation, as well as factors associated with increased usage. DESIGNS, SETTINGS, AND PARTICIPANTS: We conducted a retrospective analysis of all clinical documentation written at our healthcare system (a multifacility academic urban healthcare system) between 2015 and 2020. MAIN OUTCOMES AND MEASURES: We used string-matching and regular expressions to identify medication mentions. We conducted bivariate analyses to identify associations between brand name usage and author-, note-, and medication-level factors, and a multivariate Poisson regression to clarify independent associations between individual factors and brand usage. RESULTS: A total of 104,456,653 notes from 37,285 unique authors were included in our analysis. A total of 162,906,009 medication mentions were identified, of which 36.0% were brand name mentions with a steady year-over-year decrease. Factors associated with the usage of a brand name include: author role, years since release, length and syllabic complexity of the generic name, service type, and encounter context. Over-the-counter availability did not affect usage. There was sizable individual variation between note writers.

Prevalence and Sources of Duplicate Information in the Electronic Medical Record.

Importance: Duplicated text is a well-documented hazard in electronic medical records (EMRs), leading to wasted clinician time, medical error, and burnout. This study hypothesizes that text duplication is prevalent and increases with time and EMR size and that duplicate information is shared across authors. Objective: To examine the prevalence and scope of duplication behavior in clinical notes from a large academic health system and the factors associated with duplication. Design, Setting, and Participants: This retrospective, cross-sectional analysis of note length and content duplication rates used a set of 10 adjacent word tokens (ie, a 10-gram) sliding-window approach to identify spans of text duplicated exactly from earlier notes in a patient's record for all inpatient and outpatient notes written within the University of Pennsylvania Health System from January 1, 2015, through December 31, 2020. Text duplicated from a different author vs text duplicated from the same author was quantified. Furthermore, novel text and duplicated text per author for various note types and author types, as well as per patient record by number of notes in the record, were quantified. Information scatter, another documentation hazard, was defined as the inverse of novel text per note, and the association between information duplication and information scatter was graphed. Data analysis was performed from January to March 2022. Main Outcomes and Measures: Total, novel, and duplicate text by note type and note author were determined, as were the mean intra-author and inter-author duplication per note by type and author. Results: There were a total of 104 456 653 notes for 1 960 689 unique patients consisting of 32 991 489 889 words; 50.1% of the total text in the record (16 523 851 210 words) was duplicated from prior text written about the same patient. The duplication fraction increased year-over-year, from 33.0% for notes written in 2015 to 54.2% for notes written in 2020. Of the text duplicated, 54.1% came from text written by the same author, whereas 45.9% was duplicated from a different author. Records with more notes had more total duplicate text, approaching 60%. Note types with high information scatter tended to have low information overload, and vice versa, suggesting a trade-off between these 2 hazards under the current documentation paradigm. Conclusions and Relevance: Duplicate text casts doubt on the veracity of all information in the medical record, making it difficult to find and verify information in day-to-day clinical work. The findings of this cross-sectional study suggest that text duplication is a systemic hazard, requiring systemic interventions to fix, and simple solutions such as banning copy-paste may have unintended consequences, such as worsening information scatter. The note paradigm should be further examined as a major cause of duplication and scatter, and alternative paradigms should be evaluated.

A Mobile, Electronic Health Record-Connected Application for Managing Team Workflows in Inpatient Care.

BACKGROUND: Clinical workflows require the ability to synthesize and act on existing and emerging patient information. While offering multiple benefits, in many circumstances electronic health records (EHRs) do not adequately support these needs. OBJECTIVES: We sought to design, build, and implement an EHR-connected rounding and handoff tool with real-time data that supports care plan organization and team-based care. This article first describes our process, from ideation and development through implementation; and second, the research findings of objective use, efficacy, and efficiency, along with qualitative assessments of user experience. METHODS: Guided by user-centered design and Agile development methodologies, our interdisciplinary team designed and built Carelign as a responsive web application, accessible from any mobile or desktop device, that gathers and integrates data from a health care institution's information systems. Implementation and iterative improvements spanned January to July 2016. We assessed acceptance via usage metrics, user observations, time-motion studies, and user surveys. RESULTS: By July 2016, Carelign was implemented on 152 of 169 total inpatient services across three hospitals staffing 1,616 hospital beds. Acceptance was near-immediate: in July 2016, 3,275 average unique weekly users generated 26,981 average weekly access sessions; these metrics remained steady over the following 4 years. In 2016 and 2018 surveys, users positively rated Carelign's workflow integration, support of clinical activities, and overall impact on work life. CONCLUSION: User-focused design, multidisciplinary development teams, and rapid iteration enabled creation, adoption, and sustained use of a patient-centered digital workflow tool that supports diverse users' and teams' evolving care plan organization needs.

Context and Meaning in EHR Displays.

Many Electronic Health Record (EHRs) data displays are insensitive to their settings, contexts, and to clinicians' needs. Yet, the contexts in which the data are displayed critically affect EHR usability and patient safety. Medication prescribing is a complex task; especially sensitive to contextual variation in EHR displays as vast variations in formats and logic are often unnecessarily confusing, leading to unwanted cognitive burdens and medical errors. With examples of EHR screenshots, we illustrate contextual variations in medication and allergy displays across different EHR systems and implementations-noting often seemingly haphazard differences that can lead to misunderstandings and misinterpretations.

Effects of education on interns' verbal and electronic handoff documentation skills.

BACKGROUND: Improving handoff communications is a National Patient Safety Goal. Interns and residents are rarely taught how to safely handoff their patients. Our objective was to determine whether teaching safe handoff principles would improve handoff quality. METHODS: Our study was conducted on the inpatient services at 2 teaching hospitals. In this single-institution, randomized controlled trial, internal medicine interns (N  =  44) and residents (N  =  24) participated in a 45-minute educational session on safe handoff communication skills. Residents received additional education on effective feedback practices and were asked to provide each intern with structured feedback. Quality of interns' electronic and verbal handoffs was measured by using a Handoff Evaluation Tool created by the authors. The frequency of handoff communication failures was also assessed through semistructured phone interviews of postcall interns. RESULTS: Interns who received handoff education demonstrated superior verbal handoff skills than control interns (P < .001), while no difference was seen in electronic handoff skills. Communication failures related to code status (P < .001) and overnight tasks (P < .050) were less frequent in the intervention group. CONCLUSIONS: Interns' electronic handoff documentation skills did not improve with the intervention. This may reflect greater difficulty in changing physicians' electronic documentation habits.

A randomized-controlled trial of computerized alerts to reduce unapproved medication abbreviation use.

Abbreviation use is a preventable cause of medication errors. The objective of this study was to test whether computerized alerts designed to reduce medication abbreviations and embedded within an electronic progress note program could reduce these abbreviations in the non-computer-assisted handwritten notes of physicians. Fifty-nine physicians were randomized to one of three groups: a forced correction alert group; an auto-correction alert group; or a group that received no alerts. Over time, physicians in all groups significantly reduced their use of these abbreviations in their handwritten notes. Physicians exposed to the forced correction alert showed the greatest reductions in use when compared to controls (p=0.02) and the auto-correction alert group (p=0.0005). Knowledge of unapproved abbreviations was measured before and after the intervention and did not improve (p=0.81). This work demonstrates the effects that alert systems can have on physician behavior in a non-computerized environment and in the absence of knowledge.

Atheroprotective lipoprotein effects of a niacin-simvastatin combination compared to low- and high-dose simvastatin monotherapy.

BACKGROUND: Niacin has multiple lipoprotein effects that may provide cardiovascular benefit when added to statin monotherapy. METHODS: In this randomized, placebo-controlled trial (n = 75) of magnetic resonance imaging of carotid atherosclerosis, we performed a secondary comparison of combination niacin-statin (simvastatin 20 mg/Niacin-ER 2G [S20/N]) to monotherapy with moderate (20 mg [S20]) and high-dose (80 mg [S80]) simvastatin on lipids, apolipoproteins (apo), low density lipoprotein (LDL) and high density lipoprotein (HDL) particle subclasses, and inflammatory markers. RESULTS: At baseline, average age was 71, 72% were male, 62.5% used statins, and average LDL-cholesterol was 111 mg/dL. At 12 months, S20/N, compared to S80, significantly reduced apoB (-36.6% vs -11.9%; P = .05) and lipoprotein(a) (-18% vs +3.5%; P = .001) and had at least an equivalent effect on LDL-cholesterol (-39.3% vs -24.3%; P = .24). The combination reduced the proportion of subjects with atherogenic LDL pattern-B (50% to 11.5%) compared to S80 (56% to 56%) (P = .01). Despite increases in plasma free fatty acids (+62.4%; F = 5.65, P = .005 vs S20 and S80), plasma triglycerides (-29.4%; F = 6.88, P = .002 vs S20 and S80), and very-low-density lipoprotein (-44.2%; F = 7.94, P < .001 vs S20 and S80), levels were reduced by S20/N. S20/N increased HDL-cholesterol levels (+18.1%) as compared to S20 (0%) and S80 (+5.9%) (P < .001 vs both statin arms), largely due to an increase in HDL particle size (+4.6%; P = .01 vs both statin arms). CONCLUSIONS: We demonstrate that full-dose niacin/moderate-dose simvastatin combination has sustained benefits on atherogenic apoB lipoproteins, at least comparable to high-dose simvastatin, while also raising HDL-cholesterol. Results of large clinical trials will inform whether niacin-statin combinations reduce cardiovascular disease events.

Mechanical thrombectomy of the internal carotid artery and middle cerebral arteries for acute stroke by using the retriever device.

We report a case of mechanical thrombectomy in which a new device, the Retriever, was used for acute cerebral ischemia in the setting of extensive occlusion of the left internal carotid and middle cerebral arteries. Excellent radiographic and clinical results were obtained. The Retriever is currently approved and available for foreign body extraction and for intracranial thrombectomy when used as part of the Mechanical Embolus Removal in Cerebral Ischemia, or MERCI, clinical trial. This device was able to retrieve and remove clots efficiently from the intracranial and extracranial circulation, offering a new therapeutic alternative in the treatment of acute cerebral ischemic disease.