Implementation of a Real-Time Documentation Assistance Tool: Automated Diagnosis (AutoDx).

BACKGROUND: Clinical documentation improvement programs are utilized by most health care systems to enhance provider documentation. Suggestions are sent to providers in a variety of ways, and are commonly referred to as coding queries. Responding to these coding queries can require significant provider time and do not often align with workflows. To enhance provider documentation in a more consistent manner without creating undue burden, alternative strategies are required. OBJECTIVES: The aim of this study is to evaluate the impact of a real-time documentation assistance tool, named AutoDx, on the volume of coding queries and encounter-level outcome metrics, including case-mix index (CMI). METHODS: The AutoDx tool was developed utilizing tools existing within the electronic health record, and is based on the generation of messages when clinical conditions are met. These messages appear within provider notes and required little to no interaction. Initial diagnoses included in the tool were electrolyte deficiencies, obesity, and malnutrition. The tool was piloted in a cohort of Hospital Medicine providers, then expanded to the Neuro Intensive Care Unit (NICU), with addition diagnoses being added. RESULTS: The initial Hospital Medicine implementation evaluation included 590 encounters pre- and 531 post-implementation. The volume of coding queries decreased 57% (p < 0.0001) for the targeted diagnoses compared with 6% (p = 0.77) in other high-volume diagnoses. In the NICU cohort, 829 encounters pre-implementation were compared with 680 post. The proportion of AutoDx coding queries compared with all other coding queries decreased from 54.9 to 37.1% (p < 0.0001). During the same period, CMI demonstrated a significant increase post-implementation (4.00 vs. 4.55, p = 0.02). CONCLUSION: The real-time documentation assistance tool led to a significant decrease in coding queries for targeted diagnoses in two unique provider cohorts. This improvement was also associated with a significant increase in CMI during the implementation time period.

Diabetes Life Expectancy Prediction Model Inputs and Results From Patient Surveys Compared With Electronic Health Record Abstraction: Survey Study.

Background: Prediction models are being increasingly used in clinical practice, with some requiring patient-reported outcomes (PROs). The optimal approach to collecting the needed inputs is unknown. Objective: Our objective was to compare mortality prediction model inputs and scores based on electronic health record (EHR) abstraction versus patient survey. Methods: Older patients aged ≥65 years with type 2 diabetes at an urban primary care practice in Chicago were recruited to participate in a care management trial. All participants completed a survey via an electronic portal that included items on the presence of comorbid conditions and functional status, which are needed to complete a mortality prediction model. We compared the individual data inputs and the overall model performance based on the data gathered from the survey compared to the chart review. Results: For individual data inputs, we found the largest differences in questions regarding functional status such as pushing/pulling, where 41.4% (31/75) of participants reported difficulties that were not captured in the chart with smaller differences for comorbid conditions. For the overall mortality score, we saw nonsignificant differences (P=.82) when comparing survey and chart-abstracted data. When allocating participants to life expectancy subgroups (<5 years, 5-10 years, >10 years), differences in survey and chart review data resulted in 20% having different subgroup assignments and, therefore, discordant glucose control recommendations. Conclusions: In this small exploratory study, we found that, despite differences in data inputs regarding functional status, the overall performance of a mortality prediction model was similar when using survey and chart-abstracted data. Larger studies comparing patient survey and chart data are needed to assess whether these findings are reproduceable and clinically important.

Absence of the appendix discovered during childhood.

Absence of the appendix is rare. Isolated cases are usually discovered in adult patients or cadavers. We report the case of a 14 year old boy who was found to have no appendix on laparotomy for assumed acute appendicitis and use this opportunity to highlight the growing surgical uses of this vestigial structure.

Regular screening mammography before the diagnosis of breast cancer reduces black:white breast cancer differences and modifies negative biological prognostic factors.

Black women present with later stage breast cancers compared to white women, and their cancers are more likely to be larger, receptor negative, and undifferentiated. This study evaluated black:white differences in the stage and biology of breast cancer among women who had a screening mammogram at one of two Chicago academic medical centers within two years of the breast cancer diagnosis (regularly screened) and compared them to the black:white differences in the stage and biology of breast cancer in women who had not received mammographic screening within two years of a breast cancer diagnosis (irregularly screened.) There were no significant black:white differences in the proportion of early breast cancers (black = 74 %; white = 69 %, p = NS) in the regularly screened population or in the irregularly screened group (black = 60 %; white = 68 %, p = NS.) The regularly screened population received significantly more mammograms (58 % ≥4 mammograms) compared to the irregularly screened population (41 % ≥4 mammograms.) Black women in the regularly screened population were less likely than irregularly screened black women to have estrogen negative breast cancers (26 vs. 36 %, p < .05), progesterone negative breast cancers (35 vs. 46 %, p < .05), and poorly differentiated breast cancers (39 vs. 53 %, p < .05.) White women in the irregularly screened population also had worse prognostic factors than white women in the regularly screened population, though these were not statistically significant. Regular mammographic screening can contribute to the narrowing of black:white differences in presentation of breast cancer.

Microbial quality of water in rural communities of Trinidad

A cross-sectional study was conducted in four rural communities of northeastern Trinidad to determine the microbial quality of water supply to households and that quality's relationship to source and storage device. Of the 167 household water samples tested, total coliforms were detected in 132 of the samples (79.0 percent), fecal coliforms in 102 (61.1 percent), and E. coli in 111 (66.5 percent). There were significant differences among the towns in the proportions of the samples contaminated with coliforms (P <0.001) and E. coli (P <0.001). Of 253 strains of E. coli studied, 4 (1.6 percent) were mucoid, 9 (3.6 percent) were hemolytic, and 37 (14.6 percent) were nonsorbitol fermenters. Of 69 isolates of E. coli tested, 10 (14.5 percent) were verocytotoxigenic. Twenty-eight (14.0 percent) of 200 E. coli isolates tested belonged to enteropathogenic serogroups. Standpipe, the most common water source, was utilized by 57 (34.1 percent) of the 167 households. Treated water (pipeborne in homes, standpipes, or truckborne) was supplied to 119 households (71.3 percent) while 48 households (28.7 percent) used water from untreated sources (rain, river/stream, or well) as their primary water supply. The type of household storage device was associated with coliform contamination. Water stored in drums, barrels, or buckets was more likely to harbor fecal coliforms (74.2 percent of supplies) than was water stored in tanks (53.3 percent of samples), even after controlling for water source (P=0.04). Compared with water from other sources, water piped into homes was significantly less likely to be contaminated with total coliforms (56.9 percent versus 88.8 percent, P <0.001) and fecal coliforms (41.2 percent versus 69.8 percent, P <0.01), even when the type of storage device was taken into account. However, fecal contamination was not associated with whether the water came from a treated or untreated source. We concluded that the drinking water in rural communities in Trinidad was grossly unfit for human consumption, due both to contamination of various water sources and during household water storage (AU)

Microbial quality of water in rural communities of Trinidad / Calidad microbiológica del agua en comunidades rurales de Trinidad

A cross-sectional study was conducted in four rural communities of northeastern Trinidad to determine the microbial quality of water supply to households and that quality's relationship to source and storage device. Of the 167 household water samples tested, total coliforms were detected in 132 of the samples (79.0 por cent), fecal coliforms in 102 (61.1 por cent), and E. coli in 111 (66.5 por cent). There were significant differences among the towns in the proportion of the samples contaminated with coliforms (P < 0.001) and E. coli (P < 0.001). Of 253 strains of E. coli studied, 4 (1.6 por cent) were mucoid, 9 (3.6 por cent) were hemolytic, and 37 (14.6 por cent) were nonsorbitol fermenters. Of 69 isolates of E. coli tested, 10 (14.5 por cent) were verocytotoxigenic. Twenty-eight (14.0 por cent) of 200 E. coli isolates tested belonged to enteropathogenic serogroups. Standpipe, the most common water source, was utilized by 57 (34.1 por cent) of the 167 households. Treated water (pipeborne in homes, tandpipes, or truckborne) was supplied to 119 households (71.3 por cent), while 48 households (28.7 por cent) used water from untreated sources (rain, river/stream, or well) as their primary water supply. The type of household storage device was associated with coliform contamination. Water stored in drums, barrels, or buckets was more likely to harbor fecal coliforms (74.2 por cent of samples) htan was water stored in tanks (53.3 por cent of samples), even after controlling for water source (P = 0.04). Compared with water from other sources, water piped into homes was significantly less likely to be contaminated with total coliforms (56.9 por cent) versus 88.8 por cent, P<0.001) and fecal coliforms (41.2 por cent versus 69.8 por cent, P<0.01), even when the type of storage device was taken into account. However, fecal contamination was not associated with whether the water came from a treated or untreated source. We concluded that the drinking water in rural communities in Trinidad was grossly unfit for human consumption, due both to contamination of vaious water sources and during household water storage

Se realizó un estudio transversal en cuatro comunidades rurales del nordeste de la isla de Trinidad para determinar la calidad microbiológica de los suministros domésticos de agua y la relación entre dicha calidad y el origen del agua y los recipientes utilizados para su almacenamiento. Entre las 167 muestras de agua doméstica analizadas, se detectaron coliformes totales en 132 (79,0%), coliformes fecales en 102 (61,1%) y Escherichia coli en 111 (66,5%). Hubo diferencias significativas entre los pueblos con respecto a la proporción de muestras contaminadas con coliformes (P < 0,001) y E. coli (P < 0,001). De las 253 cepas de E. coli estudiadas, 4 (1,6%) eran mucoides, 9 (3,6%) hemolíticas y 37 (14,6%) no fermentadoras de sorbitol. De 69 aislados de E. coli en los que se analizó esta característica, 10 (14,5%) fueron citotóxicos para las células Vero. Veintiocho de 200 (14,0%) aislados de E. coli analizados pertenecían a serogrupos enteropatógenos. El origen más frecuente del agua fueron las fuentes (57 de los 167 domicilios; 34,1%). Ciento diecinueve domicilios (71,3%) recibían agua tratada (agua canalizada hasta el domicilio, de fuente o de camión cisterna), mientras que los otros 48 (28,7%) utilizaban agua no tratada (de lluvia, ríos/arroyos o pozos) como principal suministro de agua. El tipo de recipiente de almacenamiento en el domicilio se asoció con la contaminación por coliformes. El agua almacenada en bidones, barriles o cubos tenía mayores probabilidades de albergar coliformes fecales (74,2% de las muestras) que el agua almacenada en tanques (53,3% de las muestras), incluso después de controlar el efecto del origen del agua (P = 0,04). En comparación con el agua de otras fuentes, el agua canalizada hasta las casas tenía una probabilidad significativamente menor de estar contaminada por coliformes totales (56,9% frente a 88,8%; P < 0,001) y coliformes fecales (41,2% frente a 69,8%, P < 0,01), incluso después de tener en cuenta el tipo de recipiente de almacenamiento. Sin embargo, la contaminación fecal no se asoció con el origen tratado o no tratado del agua. Concluimos que el agua para beber de las comunidades rurales de Trinidad era en general no apta para el consumo humano debido a su contaminación tanto en el origen como durante el almacenamiento en el domicilio

Microbial quality of water in rural communities of Trinidad

A cross-sectional study was conducted in four rural communities of northeastern Trinidad to determine the microbial quality of water supply to households and that quality's relationship to source and storage device. Of the 167 household water samples tested, total coliforms were detected in 132 of the samples (79.0 por cent), fecal coliforms in 102 (61.1 por cent), and E. coli in 111 (66.5 por cent). There were significant differences among the towns in the proportion of the samples contaminated with coliforms (P 0.001) and E. coli (P 0.001). Of 253 strains of E. coli studied, 4 (1.6 por cent) were mucoid, 9 (3.6 por cent) were hemolytic, and 37 (14.6 por cent) were nonsorbitol fermenters. Of 69 isolates of E. coli tested, 10 (14.5 por cent) were verocytotoxigenic. Twenty-eight (14.0 por cent) of 200 E. coli isolates tested belonged to enteropathogenic serogroups. Standpipe, the most common water source, was utilized by 57 (34.1 por cent) of the 167 households. Treated water (pipeborne in homes, tandpipes, or truckborne) was supplied to 119 households (71.3 por cent), while 48 households (28.7 por cent) used water from untreated sources (rain, river/stream, or well) as their primary water supply. The type of household storage device was associated with coliform contamination. Water stored in drums, barrels, or buckets was more likely to harbor fecal coliforms (74.2 por cent of samples) htan was water stored in tanks (53.3 por cent of samples), even after controlling for water source (P = 0.04). Compared with water from other sources, water piped into homes was significantly less likely to be contaminated with total coliforms (56.9 por cent) versus 88.8 por cent, P0.001) and fecal coliforms (41.2 por cent versus 69.8 por cent, P0.01), even when the type of storage device was taken into account. However, fecal contamination was not associated with whether the water came from a treated or untreated source. We concluded that the drinking water in rural communities in Trinidad was grossly unfit for human consumption, due both to contamination of vaious water sources and during household water storage