Crowdsourcing Electronic Health Record Improvements at Scale across an Integrated Health Care Delivery System.

BACKGROUND AND OBJECTIVE: Despite widespread adoption of electronic health records (EHRs), these systems have significant room for improved efficiency and efficacy. While the idea of crowdsourcing EHR improvement ideas has been reported, little is known about how this might work across an integrated health care delivery system in practice. METHODS: Our program solicited EHR improvement submissions during two timeframes across 10 hospitals and 60 clinics in an upper-Midwest integrated health care delivery system. Submissions were primarily collected via an EHR help feature. RESULTS: A total of 262 and 294 submissions were received in 2019 and 2022, with a majority initiated from physicians (73.5 and 46.9%, 2019 and 2022) specializing in family medicine (52.0 and 59.3%). In 2022, the program reached a larger variety of personnel than 2019, with 53.0% of submissions from advanced practice providers, nurses, administrative staff, and other roles (p < 0.0001). Many ideas (36.4 and 50.0% in 2019 and 2022) reflected a lack of user understanding of EHR features and were addressed through training/education. Significant (27.1 and 25.9%) or simple (24.0 and 14.7%) EHR optimizations were required to address most remaining suggestions, with a number part of planned EHR improvement projects already (16.3 and 17.6%). CONCLUSION: Our experience using a crowdsourcing approach for EHR improvement ideas provided clinicians and staff the opportunity to address frustrations with the EHR and offered concrete feedback and solutions. While previous studies have suggested EHR technology improvements as paramount, we observed large numbers of users having a misunderstanding of EHR features, highlighting the need for improved EHR user competency and training.

Overcoming gaps: regional collaborative to optimize capacity management and predict length of stay of patients admitted with COVID-19.

OBJECTIVE: Ensuring an efficient response to COVID-19 requires a degree of inter-system coordination and capacity management coupled with an accurate assessment of hospital utilization including length of stay (LOS). We aimed to establish optimal practices in inter-system data sharing and LOS modeling to support patient care and regional hospital operations. MATERIALS AND METHODS: We completed a retrospective observational study of patients admitted with COVID-19 followed by 12-week prospective validation, involving 36 hospitals covering the upper Midwest. We developed a method for sharing de-identified patient data across systems for analysis. From this, we compared 3 approaches, generalized linear model (GLM) and random forest (RF), and aggregated system level averages to identify features associated with LOS. We compared model performance by area under the ROC curve (AUROC). RESULTS: A total of 2068 patients were included and used for model derivation and 597 patients for validation. LOS overall had a median of 5.0 days and mean of 8.2 days. Consistent predictors of LOS included age, critical illness, oxygen requirement, weight loss, and nursing home admission. In the validation cohort, the RF model (AUROC 0.890) and GLM model (AUROC 0.864) achieved good to excellent prediction of LOS, but only marginally better than system averages in practice. CONCLUSION: Regional sharing of patient data allowed for effective prediction of LOS across systems; however, this only provided marginal improvement over hospital averages at the aggregate level. A federated approach of sharing aggregated system capacity and average LOS will likely allow for effective capacity management at the regional level.

Assessing Provider-Generated Free-Text Quality in EHR-Integrated Handoff Notes.

Handoff notes are increasingly integrated within electronic health record (EHR) systems and often contain data automatically generated from the EHR and free-text narratives. We examined the quality of data entered by providers in the free-text portion of our institutional EHR handoff tool. Overall, 65% of handoff notes contained at least one error (average 1.7 errors per note). Most errors were omissions in information around patient plan/management or assessment/diagnosis rather than entry of false data. Factors associated with increased error rate were increasing hospital day number; weekend note; medical (vs. surgical) service team; and authorship by a medical student, first or fourth year resident physician, or attending physician. Our findings suggest that errors are common in handoff notes, and while these errors are not completely false data, they may provide individuals caring for patients an inaccurate understanding of patient status.

Regulation of proteins affecting NMDA receptor-induced excitotoxicity in a Huntington's mouse model.

Symptoms of Huntington's disease may be caused by a toxic insult triggered by the mutant human huntingtin (Htt) protein itself, by a maladaptive protective mechanism initiated in response to an insult, or by a combination of these. We observed a protection from N-methyl-d-aspartate (NMDA) receptor-induced excitotoxicity in striata of symptomatic N171-82Q mice, a new transgenic model of Huntington's disease. The goal of this study was to determine if NMDA receptor-mediated signalling pathways are altered in these mice. Multiple proteins of NMDA receptor and dopamine D1 receptor pathways are being regulated in ways predictive of the protection we observe. Although examining NMDA receptor subunit proteins showed no change in NR1, NR2A, or NR2B in the striata of the symptomatic mice, we observed a decrease in phosphorylation of NR1 at Ser897, previously reported to decrease NMDA receptor current. The dopamine D1 receptor, responsible for protein kinase A activation and subsequent phosphorylation of Ser897 of NR1, also showed an age-related decrease. Other proteins regulated in this disease were associated with PSD-95-like scaffolding proteins of the NMDA receptor. Specifically, we observed a decrease in membrane-associated neuronal nitric oxide synthase (nNOS), a decrease in PSD-95-like proteins, which link nNOS to the NMDA receptor complex, and a decrease in citron, a protein associated with dendritic spine formation. From these data, we conclude that the N171-82Q mice seem to be regulating, in a protective direction, many of the known effector pathways of NMDA receptor-induced excitotoxicity. These regulations, although seemingly effective in decreasing neuronal death, may in fact be causing some of the symptoms associated with the disease.

Association of NR3A with the N-methyl-D-aspartate receptor NR1 and NR2 subunits.

The NR3A subunit of the N-methyl-D-aspartate receptor has been shown to form glutamatergic receptor complexes with NR1 and NR2 subunits and excitatory glycinergic receptor complexes with NR1 alone. We developed an antibody to NR3A and, using quantitative immunoblotting techniques, determined the degree of association between the NR3A subunit and the NR1 and NR2 subunits as well as changes in these associations during development. NR3A expression peaks between postnatal days 7 and 10 in the cortex, midbrain, and hippocampus and reaches higher maximal expression levels in these areas than in the olfactory bulb and cerebellum. Immunoprecipitation experiments with an anti-NR1 antibody demonstrated that the majority of NR3A is associated with NR1 in postnatal day 10 rat cortex (80 +/- 8%), decreasing by half (38 +/- 4%) in the adult rat cortex. Using the anti-NR3A antibody in immunoprecipitation studies, we find that 9.7 +/- 0.8% of NR1, 8.7 +/- 1.8% of NR2A, and 5.0 +/- 0.6% of NR2B are associated with NR3A at postnatal day 10. These values decrease by about half in adult rat cortex. The results of this study demonstrate that NR3A is expressed, distributed, and associated with other subunits in a manner that supports its role in synaptic transmission throughout the rat brain, perhaps playing different roles during development.

Tris(benzylthiolato)bismuth. Efficient Precursor to Phase-Pure Polycrystalline Bi(2)S(3).

Details of the synthesis, physical and spectroscopic characterization, and thermal decomposition of tris(benzylthiolato)bismuth, (BnS)(3)Bi, Bn = CH(2)C(6)H(5), are presented. Results from pyrolysis of (BnS)(3)Bi demonstrate that this compound is a convenient precursor to phase-pure, polycrystalline Bi(2)S(3) with low carbon and hydrogen contamination under mild thermal conditions (ca. 275 degrees C). Flow-tube pyrolysis produces small ( approximately 1 &mgr;m) spherical particles, whereas sealed-tube pyrolysis produces 6-&mgr;m diameter spherical particles composed of radiating acicular crystallites. Bi(2)S(3) was characterized by X-ray powder diffraction and scanning electron microscopy.