A Practical Approach to Optimize Computerized Provider Order Entry Systems and Reduce Clinician Burden: Pre-Post Evaluation of Vendor-Derived "Order Friction" Data.

Computerized provider order entry (CPOE) systems have been cited as a significant contributor to clinician burden. Vendor-derived measures and data sets have been developed to help with optimization of CPOE systems. We describe how we analyzed vendor-derived Order Friction (OF) EHR log data at our health system and propose a practical approach for optimizing CPOE systems by reducing OF. We also conducted a pre-post intervention study using OF data to evaluate the impact of defaulting the frequency of urine, stool and nasal swab tests and found that all modified orders had significantly fewer changes required per order (p<0.01). Our proposed approach is a six-step process: 1) understand the ordering process, 2) understand OF data elements contextually, 3) explore ordering user-level factors, 4) evaluate order volume and friction from different order sources, 5) optimize order-level design, 6) identify high volume alerts to evaluate for appropriateness.

A scoping review of the unassisted physical exam conducted over synchronous audio-video telemedicine.

BACKGROUND: This scoping review aims to provide a broad overview of the research on the unassisted virtual physical exam performed over synchronous audio-video telemedicine to identify gaps in knowledge and guide future research. METHODS: Searches for studies on the unassisted virtual physical exam were conducted in 3 databases. We included primary research studies in English on the virtual physical exam conducted via patient-to-provider synchronous, audio-video telemedicine in the absence of assistive technology or personnel. Screening and data extraction were performed by 2 independent reviewers. RESULTS: Seventy-four studies met inclusion criteria. The most common components of the physical exam performed over telemedicine were neurologic (38/74, 51%), musculoskeletal (10/74, 14%), multi-system (6/74, 8%), neuropsychologic (5/74, 7%), and skin (5/74, 7%). The majority of the literature focuses on the telemedicine physical exam in the adult population, with only 5% of studies conducted specifically in a pediatric population. During the telemedicine exam, the patients were most commonly located in outpatient offices (28/74, 38%) and homes and other non-clinical settings (25/74, 34%). Both patients and providers in the included studies most frequently used computers for the telemedicine encounter. CONCLUSIONS: Research evaluating the unassisted virtual physical exam is at an early stage of maturity and is skewed toward the neurologic, musculoskeletal, neuropsychologic, and skin exam components. Future research should focus on expanding the range of telemedicine exam maneuvers studied and evaluating the exam in the most relevant settings, which for telemedicine is trending toward exams conducted through mobile devices and in patients' homes.

Differences in antibiotic prescriptions between direct-to-consumer telehealth and telehealth in the emergency department.

BACKGROUND: Telemedicine, which allows physicians to assess and treat patients via real-time audiovisual conferencing, is a rapidly growing modality for providing medical care. Antibiotic stewardship is one important measure of care quality, and research on antibiotic prescribing for acute respiratory infections in direct-to-consumer telemedicine has yielded mixed results. We compared antibiotic prescription rates for acute respiratory infections in two groups treated by telemedicine: (1) patients treated via a direct-to-consumer telemedicine application and (2) patients treated via telemedicine while physically inside the emergency department. METHODS: We included direct-to-consumer telemedicine and emergency department telemedicine visits for patients 18 years and older with physician-coded International Classification of Diseases, Tenth Revision acute respiratory infection diagnoses between November 2016 and December 2018. Patients in both groups were seen by the same emergency department faculty working dedicated telemedicine shifts. We compared antibiotic prescribing rates for direct-to-consumer telemedicine and emergency department telemedicine visits before and after adjustment for age, sex, and diagnosis. RESULTS: We identified a total of 468 acute respiratory infection visits: 191 direct-to-consumer telemedicine visits and 277 emergency department telemedicine visits. Overall, antibiotics were prescribed for 47% of visits (59% of direct-to-consumer telemedicine visits vs 39% of emergency department telemedicine visits; odds ratio 2.23; 95% confidence interval 1.53-3.25; P < 0.001). The difference in antibiotic prescribing rates remained significant after adjustment for age, sex, and diagnosis (odds ratio 2.49; 95% confidence interval 1.65-3.77; P < 0.001). CONCLUSION: Patients seen by the same group of physicians for acute respiratory infection were significantly more likely to be prescribed antibiotics by direct-to-consumer telemedicine care compared with telemedicine care in the emergency department. This work suggests that contextual factors rather than evaluation over video may contribute to differences in antibiotic stewardship for direct-to-consumer telemedicine encounters.

Clinical informatics during the COVID-19 pandemic: Lessons learned and implications for emergency department and inpatient operations.

In response to a pandemic, hospital leaders can use clinical informatics to aid clinical decision making, virtualizing medical care, coordinating communication, and defining workflow and compliance. Clinical informatics procedures need to be implemented nimbly, with governance measures in place to properly oversee and guide novel patient care pathways, diagnostic and treatment workflows, and provider education and communication. The authors' experience recommends (1) creating flexible order sets that adapt to evolving guidelines that meet needs across specialties, (2) enhancing and supporting inherent telemedicine capability, (3) electronically enabling novel workflows quickly and suspending noncritical administrative or billing functions in the electronic health record, and (4) using communication platforms based on tiered urgency that do not compromise security and privacy.

An Evaluation of Kiosks for Direct-to-Consumer Telemedicine Using the National Quality Forum Assessment Framework.

Background: Evaluation of direct-to-consumer (DTC) telemedicine programs has focused on care delivery via personal electronic devices. Telemedicine kiosks for the delivery of virtual urgent care services have not been systematically described. Introduction: Our institution has placed kiosks for DTC urgent care in pharmacies. These kiosks can be used without a personal electronic device. Materials and Methods: Retrospective review of adult patients using pharmacy-based kiosks (kiosk) or personal electronic devices (app) for DTC evaluation. Data for patient characteristics, wait time, technical quality, visit duration diagnosis codes, follow-up recommendations, and whether the patient was traveling were compared. Results were interpreted using the National Quality Forum framework for telemedicine service evaluation, focused on access, experience, and effectiveness. Comparisons were made using chi-square test, Student's t-test, and Wilcoxon rank-sum tests. Results: Over 1 year there were 1,996 DTC visits; 238 (12%) initiated from kiosks. Kiosk patients were slightly older (mean age 38 ± 13 vs. 35 ± 11; p < 0.001), more likely to be male (52% vs. 39%; p < 0.001), more likely to be remote from home (25% vs. 3%; p < 0.001), and had less technical difficulty (10% vs. 19%; p = 0.003). Referral for urgent in-person evaluation was low in both groups (10% kiosk vs. 16%; app p = 0.017). Discussion: Kiosks may increase access to care and improve technical experience. Low urgent referral rates suggest effective care for both types of visit. Conclusions: Despite their potential advantages, kiosk visits accounted for a minority of overall visits for our DTC telemedicine service line, and daily use of each kiosk location was low.

A telehealth program to perform medical screening examinations.

The importance of a timely medical screening examination on ED throughput, efficiency, and patient safety cannot be underestimated. This article describes a telemedicine program based on the provider in triage model that uses physician assistants and NPs to improve patient door-to-diagnostic evaluation times in the ED.

Telemedicine Evaluations for Low-Acuity Patients Presenting to the Emergency Department: Implications for Safety and Patient Satisfaction.

Background:Telemedicine is being rapidly adopted by traditional health care systems. We have used telemedicine in a program we call Express Care to allow a single physician to remotely perform evaluations of low-acuity patients.Materials and Methods:We conducted a retrospective cohort study of quality assurance data comparing low-acuity patients treated by an emergency department (ED) physician through telemedicine (Express Care) with those treated by an ED physician in person between July 16, 2016 and September 30, 2017. We compared patient demographics, length of stay (LOS), visit severity as measured by emergency severity index (ESI), visit diagnosis type, return visits, and patient satisfaction scores.Results:There were 3,266 low-acuity patients seen through telemedicine and 21,129 seen in person during the observation period. Patients receiving evaluation by telemedicine were younger (mean age ± standard deviation [in years]: 42 ± 18 vs. 45 ± 17; p < 0.001) and more likely to be male (51% vs. 46%; p < 0.001). Median ESI was slightly lower for patients treated by telemedicine [4 (4-5) vs. 4 (4-4); p < 0.001], and there were modest differences in diagnosis type between the two groups. Median ED LOS was 63.6 (interquartile range [IQR] 42.6-93.6) min for telemedicine patients and 133.8 (IQR 90.6-196.8) min for patients seen in person (p < 0.001). Seventy-two hour returns (3.4% vs. 3.0%; p = 0.302) and 72-h returns requiring admission (0.2% vs. 0.3%; p = 0.252) were similar between groups. Patient satisfaction scores were also similar between the groups.Conclusion:Telemedicine evaluation for ED patients can be effective and safe when treating low-acuity conditions without compromising patient satisfaction.

Antibiotic Prescribing Practices: Is There a Difference Between Patients Seen by Telemedicine Versus Those Seen In-Person?

Background: Direct-to-consumer telemedicine is becoming part of mainstream medicine, but questions exist regarding the quality of care provided. We assessed antibiotic stewardship, one measure of quality, by comparing antibiotic prescription rates for acute respiratory infections (ARIs) between patients seen by telemedicine and patients seen in-person in two urban emergency departments (EDs). Methods: In two urban EDs where low-acuity patients in the ED have the option of being seen by telemedicine rather than in-person, we analyzed telemedicine and in-person visits of patients ≥18 years who received ARI diagnoses between July 2016 and September 2017. The identified ARI telemedicine visits were matched to in-person visits by diagnosis, treatment hospital, and Emergency Severity Index level. We compared antibiotic prescribing rates for telemedicine and in-person visits. Results: We identified 260 telemedicine visits and compared with 260 matched in-person visits. Antibiotics for ARIs were prescribed for 29% of telemedicine visits and 28% of in-person visits (odds ratio [OR] 1.038; 95% confidence interval [CI] 0.71-1.52; p = 0.846). This finding did not materially change after adjustment for age and gender (adjusted OR 1.034; 95% CI 0.70-1.53; p = 0.86). Conclusions: Antibiotic prescribing rates for ARIs were similar for patients seen by telemedicine and patients seen in-person at two urban EDs. If differences in antibiotic stewardship between telemedicine and in-person encounters are found, contextual factors unrelated to the video-based evaluation should be investigated.

A Novel Emergency Department-Based Telemedicine Program: How Do Older Patients Fare?

Introduction:When we started using telemedicine to treat low acuity patients in the emergency department (ED), we assumed that this voluntary treatment pathway would primarily be used by younger patients. We were surprised to find that a significant portion of patients evaluated by telemedicine were older adults.Materials and Methods:We conducted a retrospective cohort study of quality assurance data. Adult ED patients at an urban academic medical center who had their care provided by telemedicine from July 2016 to September 2017 were included. We measured demographic characteristics, ED length of stay (LOS), triage severity score, X-ray orders placed, ED revisit within 72 h, need for change in treatment plan or admission on 72-h return, and patient satisfaction.Results:Of 1,592 patients evaluated, 18% were age 65 and older. Older patients were more likely to be evaluated for wound care and less likely to be evaluated for nontraumatic connective tissue illnesses. Older patients also had shorter median LOS (59 min vs. 63 min). Unplanned 72-h return (2% vs. 2%), likelihood to have a change in treatment on return (1% vs. 0.2%), and patient satisfaction were similar between age groups. The percentage of patients who returned in 72 h requiring admission were similar between age groups (0.4% vs. 0.1% p = 0.325). Sensitivity analysis with an age threshold at 75 years did not change primary results.Conclusion:These findings suggest that among low acuity patients there are groups of older adults for whom an ED telemedicine evaluation can provide safe and effective medical care that is satisfactory to patients.