The potential of virtual triage AI to improve early detection, care acuity alignment, and emergent care referral of life-threatening conditions.

Objective: To evaluate the extent to which patient-users reporting symptoms of five severe/acute conditions requiring emergency care to an AI-based virtual triage (VT) engine had no intention to get such care, and whose acuity perception was misaligned or decoupled from actual risk of life-threatening symptoms. Methods: A dataset of 3,022,882 VT interviews conducted over 16 months was evaluated to quantify and describe patient-users reporting symptoms of five potentially life-threatening conditions whose pre-triage healthcare intention was other than seeking urgent care, including myocardial infarction, stroke, asthma exacerbation, pneumonia, and pulmonary embolism. Results: Healthcare intent data was obtained for 12,101 VT patient-user interviews. Across all five conditions a weighted mean of 38.5% of individuals whose VT indicated a condition requiring emergency care had no pre-triage intent to consult a physician. Furthermore, 61.5% intending to possibly consult a physician had no intent to seek emergency medical care. After adjustment for 13% VT safety over-triage/referral to ED, a weighted mean of 33.5% of patient-users had no intent to seek professional care, and 53.5% had no intent to seek emergency care. Conclusion: AI-based VT may offer a vehicle for early detection and care acuity alignment of severe evolving pathology by engaging patients who believe their symptoms are not serious, and for accelerating care referral and delivery for life-threatening conditions where patient misunderstanding of risk, or indecision, causes care delay. A next step will be clinical confirmation that when decoupling of patient care intent from emergent care need occurs, VT can influence patient behavior to accelerate care engagement and/or emergency care dispatch and treatment to improve clinical outcomes.

How Virtual Triage Can Improve Patient Experience and Satisfaction: A Narrative Review and Look Forward.

Objective: To complete a review of the literature on patient experience and satisfaction as relates to the potential for virtual triage (VT) or symptom checkers to enhance and enable improvements in these important health care delivery objectives. Methods: Review and synthesis of the literature on patient experience and satisfaction as informed by emerging evidence, indicating potential for VT to favorably impact these clinical care objectives and outcomes. Results/Conclusions: VT enhances potential clinical effectiveness through early detection and referral, can reduce avoidable care delivery due to late clinical presentation, and can divert primary care needs to more clinically appropriate outpatient settings rather than high-acuity emergency departments. Delivery of earlier and faster, more acuity level-appropriate care, as well as patient avoidance of excess care acuity (and associated cost), offer promise as contributors to improved patient experience and satisfaction. The application of digital triage as a front door to health care delivery organizations offers care engagement that can help reduce patient need to visit a medical facility for low-acuity conditions more suitable for self-care, thus avoiding unpleasant queues and reducing microbiological and other patient risks associated with visits to medical facilities. VT also offers an opportunity for providers to make patient health care experiences more personalized.

The Role of Virtual Triage in Improving Clinician Experience and Satisfaction: A Narrative Review.

Objective: This review examines the literature on improving clinician satisfaction with a focus on what has been most effective in improving experience from the perspective of clinicians, and the potential role that virtual triage (VT) technology can play in delivering positive clinician experiences that improve clinical care, and bring value to health care delivery organizations (HDOs). Methods: Review and synthesis of evidence on clinician satisfaction indicating a potential for VT to favorably impact clinician experience, sense of effectiveness, efficiency, and reduction of administrative task burden. Analysis considers how to conceptualize and the value of improving clinician experience, leading clinician dissatisfiers, and the potential role of VT in improving clinician experience/satisfaction. Results: Contributors to poor clinician experience/satisfaction where VT could have a beneficial impact include better managing resource limitations, administrative workload, lack of care coordination, information overload, and payer interactions. VT can improve clinician experience through the technology's ability to leverage real-time actionable data clinicians can use, streamlining patient-clinician communications, personalizing care delivery, optimizing care coordination, and better aligning digital/virtual services with clinical practice. From an organizational perspective, improvements in clinician experience and satisfaction derive from establishing an effective digital back door, increasing the clinical impact of and satisfaction derived from telemedicine and virtual care, and enhancing clinician centricity. Conclusions: By embracing digital transformation and implementing solutions such as VT that focus on improving patient and clinician experience, HDOs can address barriers to delivery of high-quality, efficient, and cost-effective care. VT is a digital health tool that can create a more streamlined and satisfying experience for clinicians and the patients they care for. VT is a technology solution that can help clinicians make faster more informed decisions, reduces avoidable care, improves communication with patients and within care teams, and lowers their administrative burden so they have more quality time to care for patients.

Leveraging identity and access management technology to accelerate emergency COVID-19 vaccine delivery.

COVID-19-related vaccine demand and delivery volume challenged delivery organizations as few crises have. Imperatives to ensure security of patient information, defend against cybersecurity threats, and accurately identify/authenticate clinician identity for patients remained unchanged. Deployment of identity access and management (IAM) and single sign-on (SSO) can accelerate operationalization of a vaccine delivery center when urgently needed in a crisis. Innovative application of existing IAM/SSO technology, combined with an identity governance solution, greatly accelerated vaccine delivery. Secure access enabled by IAM technology facilitated a rapid expansion (25 minutes) where 500 new vaccine delivery personnel were identified and authenticated during a period of high pandemic incidence. Existing digital identity solutions enabled a vaccine delivery organization to accelerate secure IAM of clinical staff during the peak of the COVID-19 pandemic. Existing IAM investments and capabilities that are widely implemented in nations with mature health information technology systems can greatly accelerate standing up emergent vaccine delivery capabilities and sites in the midst of a public health crisis.

Medical Scribes: Symptom or Cause of Impeded Evolution of a Transformative Artificial Intelligence in the Electronic Health Record?

Studies have quantified various specific benefits related to the use of medical scribes, finding physician workflow and productivity improvements, with some demonstrating marginal value or detrimental impact. However, this evidence base misses a critical underlying issue with the expanding number of physicians using medical scribes routinely. There are an estimated 28,000-33,000 peer reviewed biomedical journals worldwide, currently publishing an estimated 1.8-2 million scientific articles every year. Over a typical physician's career from the 11-13 years of undergraduate through medical school and specialty/residency training as well as 34-36 practice/care delivery years beyond (to age 65), this yields 84-94+ million peer reviewed journal articles that are published in the global medical literature and to be potentially consumed/ considered over a roughly 47-year career. Clinical trial results in various stages of peer review, with 409,000 clinical trials registered in 2022, augment this massive volume of new clinical and bioscience information that clinicians might utilize to advance their care delivery by over 19 million bioscientific reports over a lifetime of training and care delivery. Inclusive of clinical trial reports and peer reviewed journal articles, a physician might derive clinical care value from an expanding career-long evidence base of 103-113+ million scientific communications. Even if only 0.1 percent of the global output of biomedical science has clinical relevance to a highly specialized physician, the narrowed career-long total remains a staggering 103,000 journal publications and clinical trial reports. For physicians with a more general and diverse clinical focus such as family medicine, emergency medicine physicians, and hospitalists, if 1 percent of newly published evidence-based literature is pertinent, the total career-long estimate is over 1 million journal articles and clinical trials to be reviewed and clinically integrated. As a result, a challenging issue created by the increasing role of medical scribes is not just evaluating their value (or lack thereof) for practicing physicians in their workflows and productivity. Rather it concerns the impact that medical scribes may be having by decoupling physicians from the iterative technological and cognitive progression of the electronic health record (EHR) and its evolving artificial intelligence (AI), which can facilitate the integration of the year-over-year proliferation of clinically pertinent new scientific evidence into a physician's practice of medicine. This commentary addresses the challenge to the evolution of the AI of the EHR posed by physicians' increasing use of and reliance upon medical scribes, and highlights how medical scribes may also, inadvertently, isolate and insulate physicians from their essential role in continuous refinement and advancement of EHR AI. Consideration is given to the broader challenge of inadequate focus and resources needed across sectors to drive the evolution of AI in the EHR, and associated health informatics research, as a US national priority.

COVID-19 surge readiness: use cases demonstrating how hospitals leveraged digital identity access management for infection control and pandemic response.

BACKGROUND: Surging volumes of patients with COVID-19 and the high infectiousness of SARS-CoV-2 challenged hospital infection control/safety, staffing, care delivery and operations as few crises have. Imperatives to ensure security of patient information, defend against cybersecurity threats and accurately identify/authenticate patients and staff were undiminished, which fostered creative use cases where hospitals leveraged identity access and management (IAM) technologies to improve infection control and minimise disruption of clinical and administrative workflows. METHODS: Working with a leading IAM solution provider, implementation personnel in the USA and UK identified all hospitals/health systems where an innovative use of IAM technology improved facility infection control and pandemic response management. Interviews/communications with hospital clinical informatics leaders collected information describing the use case deployed. RESULTS: Eight innovative/valuable hospital use cases are described: symptom-free attestation by clinicians at shift start; detection of clinician exposure/contact tracing; reporting of clinician temperature checks; inpatient telehealth consults in isolation units; virtual visits between isolated patients and families; touchless single sign-on authentication; secure access enabled for rapid expansion of personnel working remotely; and monitoring of temporary worker attendance. DISCUSSION: No systematic, comprehensive survey of all implemented IAM client sites was conducted, and other use cases may be undetected. A standardised reporting/information sharing vehicle is needed whereby IAM use cases aiding facility pandemic response and infection control can be disseminated. CONCLUSIONS: Clinical care, infection control and facility operations were improved using IAM solutions during COVID-19. Facility end-user innovation in how IAM solutions are deployed can improve infection control/patient safety, care delivery and clinical workflows during surges of epidemic infectious diseases.

No Retrenchment From Employee Empowerment: Employer Wellness Imperatives and Opportunities Emerging From the COVID-19 Pandemic.

The impact of two years of the COVID-19 pandemic on the relationship between employers and employees are explored, including changing employee sensibilities with respect to future employment, work-life balance, remote and flexible work, and the great resignation. Lasting work changes induced by the pandemic expand employee empowerment and demand for greater work flexibility. Flexibility no longer provides employers a unique selling point and hiring/retention competitiveness - it has become an expected standard. Evolving workplace expectations are tied to realizations of the value of work within the broader context of employees' lives, changing business culture across many industries. Demand for increased work/employment individualization and personalization overlaps unprecedented personalization of and power of mobile technologies. Human-centered employee management in the post-COVID-19 era will become imperative, with many opportunities for employers to enable greater impact in employee wellness and health promotion driven by deploying compelling virtual-remote engagement and behavioral change technologies.

A multinational survey of patient utilization of and value conveyed through virtual symptom triage and healthcare referral.

Objective: To describe the use patterns, impact and derived patient-user value of a mobile web-based virtual triage/symptom checker. Methods: Online survey of 2,113 web-based patient-users of a virtual triage/symptom checker was completed over an 8-week period. Questions focused on triage and care objectives, pre- and post-triage care intent, frequency of use, value derived and satisfaction with virtual triage. Responses were analyzed and stratified to characterize patient-user pre-triage and post-triage intent relative to triage engine output. Results: Seventy-eight percent of virtual triage users were female, and 37% were 18-24 years old or younger, 28% were 25-44, 16% were 45-54, and 19% were 55 years or older; 41.2% completed the survey from the U.S., 12.5% from the U.K., 9.1% from Canada, 5.6% from India, 3.8% from South Africa. Motivations were to determine need to consult a physician (44.2%), to secure medical advice without visiting a physician (21.0%), and to confirm a diagnosis received (14.2%). Forty-three percent were first time users of virtual triage, 36.6% utilized a triage engine at least once every few months or more often. Pre-triage, 40.5% did not know what level of healthcare they were planning to utilize, 33.9% stated they intended to seek a physician consultation, 23.7% engage self-care and 1.8% seek emergency care. Virtual triage recommended 56.8% of patient-users consult a physician, 33.8% seek emergency care and 9.4% engage self-care. In three-fourths, virtual triage helped users decide level of care to pursue. Among 74.1%, triage recommended care different than pre-triage intentions. Post-triage, those who remained uncertain of their care path decreased by 25.4%. Patient-user experience and satisfaction with virtual triage was high, with 80.1% stating that they were highly likely or likely to use it again, and interest in and willingness to use telemedicine doubled. Conclusion: Virtual triage successfully redirected patient-users who initially planned to seek an inappropriate level of care acuity, reduced patient uncertainty of care path, and doubled the percentage of patients amenable to telemedicine and virtual health engagement. Patient-users were highly satisfied with virtual triage and the virtual triage patient experience, and a large majority will use virtual triage recurrently in the future.

Public health nonfeasance, misfeasance and malfeasance in the U.S. Government Response to COVID-19.

In the midst of the political leadership crisis caused by the COVID-19 pandemic in the United States, a framework of public health nonfeasance, misfeasance and malfeasance is described in order to define, categorize and understand the various forms of public health performance failure of the U.S. government during the COVID-19 outbreak response thus far. The framework in turn prompts a number of critical ethical and legal questions whose consideration are in the nation's current and future public health interest, as the nation struggles to engage effective disease control measures to reduce spread of this, and future, pandemics.

Electronic Health Record Workstation Single Sign-on: A Quantification of Time Liberated for Nurses to Care for Patients.

OBJECTIVE: The aim of this study was to quantify the impact of electronic health record (EHR) workstation single sign-on (SSO) for nurses. BACKGROUND: SSO was implemented in 19 hospitals for expedited EHR access. METHODS: Login durations before and after SSO implementation were compared, and the financial value of nursing time liberated from keyboard was estimated. Stratified analyses show time liberated and financial value by staffing level and system size. RESULTS: First-of-shift login was reduced by 5.3 seconds (15.3%) and reconnect duration was reduced by 20.4 seconds (69.9%). SSO liberated 27,962.4 hours of nursing time from keyboard login per year across 19 facilities, and 1,471.7 hours/year/facility, valued at $52,112/facility and $990,128 for 19 hospitals. Time value ranges from $201,835 per year for a 5-hospital system with 300 nurses per facility to $672,790 per year for a 10-facility system with 500 nurses per hospital. CONCLUSIONS: Nurses gained substantial time liberated from EHR keyboard by SSO for patient care, having significant financial value for the organization.

Reducing pediatric asthma hospital length of stay through evidence-based quality improvement and deployment of computerized provider order entry.

Objective: Evaluate the impact of multi-component quality improvement for pediatric asthma care focusing on serial use of an evidence-based clinical pathway via paper order sets, pathway integration into computerized provider order entry (CPOE), use of a clinical respiratory score (CRS) and a discharge checklist. Methods: Outcomes were assessed over three intervention periods and 50 months on: time to beta-agonist and steroid first administration, frequency of readmissions and hospital length of stay. A general linear model estimated mean log(LOS) over time and between study periods. Time to discharge was transformed using the natural logarithm. Results: No improvements in time to first beta-agonist or steroid administration were observed. There was a reduction in 100-day readmissions (p = 0.008): decreasing from 7.4 to 2.1% after introduction of paper order sets and CRS (adjusted p = 0.04); to 3.9% after CPOE implementation (adjusted p = 0.53) and to 2.2% when a discharge checklist was added (adjusted p = 0.01). There was a statistically significant reduction in LOS between study periods (p = 0.015). The geometric mean LOS in hours during study periods 1-4 were: 34.8 (95% CI: 32.2, 37.6), 29.3 (95% CI: 27.5, 31.3), 29.0 (95% CI: 27.0, 31.3) and 23.1 (95% CI: 22.1, 24.2). Pair-wise comparisons between periods were statistically significant (adjusted p ≤ 0.003), except for Periods 2 and 3 (adjusted p = 0.83). Conclusions: Hospital length of stay and 100-day readmissions rate in a predominantly Hispanic, Medicaid patient population were reduced by utilization of an evidence-based best practices asthma management pathway and CRS within CPOE, combined with a checklist to expedite discharge.

The Impact of Order Source Misattribution on Computerized Provider Order Entry (CPOE) Performance Metrics.

BACKGROUND: One strategy to foster adoption of computerized provider order entry (CPOE) by physicians is the monthly distribution of a list identifying the number and use rate percentage of orders entered electronically versus on paper by each physician in the facility. Physicians care about CPOE use rate reports because they support the patient safety and quality improvement objectives of CPOE implementation. Certain physician groups are also motivated because they participate in contracted financial and performance arrangements that include incentive payments or financial penalties for meeting (or failing to meet) a specified CPOE use rate target. Misattribution of order sources can hinder accurate measurement of individual physician CPOE use and can thereby undermine providers' confidence in their reported performance, as well as their motivation to utilize CPOE. Misattribution of order sources also has significant patient safety, quality, and medicolegal implications. OBJECTIVE: This analysis sought to evaluate the magnitude and sources of misattribution among hospitalists with high CPOE use and, if misattribution was found, to formulate strategies to prevent and reduce its recurrence, thereby ensuring the integrity and credibility of individual and facility CPOE use rate reporting. METHODS: A detailed manual order source review and validation of all orders issued by one hospitalist group at a midsize community hospital was conducted for a one-month study period. RESULTS: We found that a small but not dismissible percentage of orders issued by hospitalists-up to 4.18 percent (95 percent confidence interval, 3.84-4.56 percent) per month-were attributed inaccurately. Sources of misattribution by department or function were as follows: nursing, 42 percent; pharmacy, 38 percent; laboratory, 15 percent; unit clerk, 3 percent; and radiology, 2 percent. Order management and protocol were the most common correct order sources that were incorrectly attributed. CONCLUSION: Order source misattribution can negatively affect reported provider CPOE use rates and should be investigated if providers perceive discrepancies between reported rates and their actual performance. Preventive education and communication efforts across departments can help prevent and reduce misattribution.

Secure Clinical Texting: Patient Risk in High-Acuity Care.

The Joint Commission recently reversed its prior authorization of the use of secure clinical texting to issue patient care orders, now again prohibiting texting of orders. However, the potential sole or exclusive use of clinical texts to transmit other patient care information beyond care orders still poses a risk to patient safety in high acuity care because of text transmission delays resulting from carrier-dependent latency. Although texting in routine patient care may deliver high value to clinicians, the risk of latency and delayed receipt of clinically urgent or time-sensitive texted patient information in high-acuity care settings can harm patients. We completed a review of 19 secure clinical text vendor websites, finding that 16 of 19 (84 percent) market their products for use specifically in high-acuity and critical patient care. The secure clinical texting industry needs the policy guidance of The Joint Commission and health information technology professionals to minimize risk to patients, clinicians, and hospital systems as secure clinical texting becomes standard accepted practice.

Clinical impact and value of workstation single sign-on.

BACKGROUND: CHRISTUS Health began implementation of computer workstation single sign-on (SSO) in 2015. SSO technology utilizes a badge reader placed at each workstation where clinicians swipe or "tap" their identification badges. OBJECTIVE: To assess the impact of SSO implementation in reducing clinician time logging in to various clinical software programs, and in financial savings from migrating to a thin client that enabled replacement of traditional hard drive computer workstations. METHODS: Following implementation of SSO, a total of 65,202 logins were sampled systematically during a 7day period among 2256 active clinical end users for time saved in 6 facilities when compared to pre-implementation. Dollar values were assigned to the time saved by 3 groups of clinical end users: physicians, nurses and ancillary service providers. RESULTS: The reduction of total clinician login time over the 7day period showed a net gain of 168.3h per week of clinician time - 28.1h (2.3 shifts) per facility per week. Annualized, 1461.2h of mixed physician and nursing time is liberated per facility per annum (121.8 shifts of 12h per year). The annual dollar cost savings of this reduction of time expended logging in is $92,146 per hospital per annum and $1,658,745 per annum in the first phase implementation of 18 hospitals. Computer hardware equipment savings due to desktop virtualization increases annual savings to $2,333,745. Qualitative value contributions to clinician satisfaction, reduction in staff turnover, facilitation of adoption of EHR applications, and other benefits of SSO are discussed. CONCLUSIONS: SSO had a positive impact on clinician efficiency and productivity in the 6 hospitals evaluated, and is an effective and cost-effective method to liberate clinician time from repetitive and time consuming logins to clinical software applications.

Toward the Elimination of Paper Orders: Managing the Challenge of Low Frequency Physician Users of Computerized Patient Order Entry (CPOE).

With the adoption of Computerized Patient Order Entry (CPOE), many physicians - particularly consultants and those who are affiliated with multiple hospital systems - are faced with the challenge of learning to navigate and commit to memory the details of multiple EHRs and CPOE software modules. These physicians may resist CPOE adoption, and their refusal to use CPOE presents a risk to patient safety when paper and electronic orders co-exist, as paper orders generated in an electronic ordering environment can be missed or acted upon after delay, are frequently illegible, and bypass the Clinical Decision Support (CDS) that is part of the evidence-based value of CPOE. We defined a category of CPOE Low Frequency Users (LFUs) - physicians issuing a total of less than 10 orders per month - and found that 50.4% of all physicians issuing orders in 3 urban/suburban hospitals were LFUs and actively issuing orders across all shifts and days of the week. Data are presented for 2013 on the number of LFUs by month, day of week, shift and facility, over 2.3 million orders issued. A menu of 6 options to assist LFUs in the use of CPOE, from which hospital leaders could select, was instituted so that paper orders could be increasingly eliminated. The options, along with their cost implications, are described, as is the initial option selected by hospital leaders. In practice, however, a mixed pattern involving several LFU support options emerged. We review data on how the option mix selected may have impacted CPOE adoption and physician use rates at the facilities. The challenge of engaging LFU physicians in CPOE adoption may be common in moderately sized hospitals, and these options can be deployed by other systems in advancing CPOE pervasiveness of use and the eventual elimination of paper orders.