Clinical Documentation During Scribed and Non-scribed Ophthalmology Office Visits.

PURPOSE: Observe the impact of employing scribes on documentation efficiency in ophthalmology clinics. DESIGN: Single-center retrospective cohort study. PARTICIPANTS: A total of 29,997 outpatient visits conducted by seven attending ophthalmologists between 1/1/2018 and 12/31/2019 were included in the study; 18,483 with a scribe present during the encounter and 11,514 without a scribe present. INTERVENTION: Use of a scribe. MAIN OUTCOME MEASURES: Total physician documentation time, physician documentation time during and after the visit, visit length, time to chart closure, note length, and percent of note text edited by physician. RESULTS: Total physician documentation time was significantly less when working with a scribe (mean ± SD, 4.7 ± 2.9 vs. 7.6 ± 3.8 minutes/note, P<.001), as was documentation time during the visit (2.8 ± 2.2 vs. 5.9 ± 3.1 minutes/note, P<.001). Physicians also edited scribed notes less, deleting 1.9 ± 4.4% of scribes' draft note text and adding 14.8 ± 11.4% of the final note text, compared to deleting 6.0 ± 9.1%(P<.001) of draft note text and adding 21.2 ± 15.3%(P<.001) of final note text when not working with a scribe. However, physician after-visit documentation time was significantly higher with a scribe for 3 of 7 physicians (P<.001). Scribe use was also associated with an office visit length increase of 2.9 minutes (P<.001) per patient and time to chart closure of 3.0 hours (P<.001), according to mixed-effects linear models. CONCLUSIONS: Scribe use was associated with increased documentation efficiency through lower total documentation time and less note editing by physicians. However, the use of a scribe was also associated with longer office visit lengths and time to chart closure. The variability in the impact of scribe use on different measures of documentation efficiency leaves unanswered questions about best practices for the implementation of scribes, and warrants further study of effective scribe use.

Methods for Large-Scale Quantitative Analysis of Scribe Impacts on Clinical Documentation.

Many medical providers employ scribes to manage electronic health record (EHR) documentation. Prior studies have shown the benefits of scribes, but no large-scale study has quantitively assessed scribe impact on documentation workflows. We propose methods that leverage EHR data for identifying scribe presence during an office visit, measuring provider documentation time, and determining how notes are edited and composed. In a case study, we found scribe use was associated with less provider documentation time overall (averaging 2.4 minutes or 39% less time, p < 0.001), fewer note edits by providers (8.4% less added and 4.2% less deleted text, p < 0.001), but significantly more documentation time after the visit for four out of seven providers (p < 0.001) and no change in the amount of copied and imported note text. Our methods could validate prior study results, identify variability for determining best practices, and determine that scribes do not improve all aspects of documentation.

FX11 inhibits aerobic glycolysis and growth of neuroblastoma cells.

BACKGROUND: The MYC family of proteins promotes neuroblastoma tumorigenesis at least in part through the induction of aerobic glycolysis by promoting the transcription of key glycolytic enzymes, such as LDHA. FX11 is a selective inhibitor of LDHA that has demonstrated preclinical efficacy in adult cancers. Herein, we hypothesized that FX11 would inhibit aerobic glycolysis and block growth of neuroblastoma cells. METHODS: We surveyed 3 MYCN-single copy and 5 MYCN-amplified neuroblastoma cell lines to correlate C-MYC/N-MYC protein levels with LDHA expression. Cell viability was measured with FX11 using a tetrazolium-based assay. Cell cycle analysis using propidium iodide with flow cytometry was performed to evaluate for growth arrest. Immunoblotting demonstrated PARP and Caspase 3 cleavage as evidence of apoptosis. RESULTS: LDHA is frequently expressed in both MYCN--amplified and MYCN-single copy cell lines. N-MYC and C-MYC protein levels did not correlate with LDHA protein expression. FX11 inhibits aerobic glycolysis and growth in three MYCN-amplified and one MYCN-single copy neuroblastoma cell lines. FX11 induces modest G1 cell cycle arrest with selective induction of apoptosis. CONCLUSION: Small molecule LDHA inhibition is capable of blocking aerobic glycolysis and growth of neuroblastoma cell lines in vitro and merits further in vivo evaluation of its preclinical efficacy in neuroblastomas.

Induced differentiation inhibits sphere formation in neuroblastoma.

Neuroblastoma arises from the neural crest, the precursor cells of the sympathoadrenal axis, and differentiation status is a key prognostic factor used for clinical risk group stratification and treatment strategies. Neuroblastoma tumor-initiating cells have been successfully isolated from patient tumor samples and bone marrow using sphere culture, which is well established to promote growth of neural crest stem cells. However, accurate quantification of sphere-forming frequency of commonly used neuroblastoma cell lines has not been reported. Here, we show that MYCN-amplified neuroblastoma cell lines form spheres more frequently than non-MYCN-amplified cell lines. We also show that sphere formation is directly sensitive to cellular differentiation status. 13-cis-retinoic acid is a clinically used differentiating agent that induces a neuronal phenotype in neuroblastoma cells. Induced differentiation nearly completely blocked sphere formation. Furthermore, sphere formation was specifically FGF-responsive and did not respond to increasing doses of EGF. Taken together, these data suggest that sphere formation is an accurate method of quantifying the stemness phenotype in neuroblastoma.