Quality of Layperson CPR Instructions From Artificial Intelligence Voice Assistants.

This case series study evaluates responses from 4 artificial intelligence voice assistance on CPR questions from laypersons.

A Pilot of Digital Whiteboards for Improving Patient Satisfaction in the Emergency Department: Nonrandomized Controlled Trial.

BACKGROUND: Electronic paper (E-paper) screens use electrophoretic ink to provide paper-like low-power displays with advanced networking capabilities that may potentially serve as an alternative to traditional whiteboards and television display screens in hospital settings. E-paper may be leveraged in the emergency department (ED) to facilitate communication. Providing ED patient status updates on E-paper screens could improve patient satisfaction and overall experience and provide more equitable access to their health information. OBJECTIVE: We aimed to pilot a patient-facing digital whiteboard using E-paper to display relevant orienting and clinical information in real time to ED patients. We also sought to assess patients' satisfaction after our intervention and understand our patients' overall perception of the impact of the digital whiteboards on their stay. METHODS: We deployed a 41-inch E-paper digital whiteboard in 4 rooms in an urban, tertiary care, and academic ED and enrolled 110 patients to understand and evaluate their experience. Participants completed a modified Hospital Consumer Assessment of Health Care Provider and Systems satisfaction questionnaire about their ED stay. We compared responses to a matched control group of patients triaged to ED rooms without digital whiteboards. We designed the digital whiteboard based on iterative feedback from various departmental stakeholders. After establishing IT infrastructure to support the project, we enrolled patients on a convenience basis into a control and an intervention (digital whiteboard) group. Enrollees were given a baseline survey to evaluate their comfort with technology and an exit survey to evaluate their opinions of the digital whiteboard and overall ED satisfaction. Statistical analysis was performed to compare baseline characteristics as well as satisfaction. RESULTS: After the successful prototyping and implementation of 4 digital whiteboards, we screened 471 patients for inclusion. We enrolled 110 patients, and 50 patients in each group (control and intervention) completed the study protocol. Age, gender, and racial and ethnic composition were similar between groups. We saw significant increases in satisfaction on postvisit surveys when patients were asked about communication regarding delays (P=.03) and what to do after discharge (P=.02). We found that patients in the intervention group were more likely to recommend the facility to family and friends (P=.04). Additionally, 96% (48/50) stated that they preferred a room with a digital whiteboard, and 70% (35/50) found the intervention "quite a bit" or "extremely" helpful in understanding their ED stay. CONCLUSIONS: Digital whiteboards are a feasible and acceptable method of displaying patient-facing data in the ED. Our pilot suggested that E-paper screens coupled with relevant, real-time clinical data and packaged together as a digital whiteboard may positively impact patient satisfaction and the perception of the facility during ED visits. Further study is needed to fully understand the impact on patient satisfaction and experience. TRIAL REGISTRATION: ClinicalTrials.gov NCT04497922; https://clinicaltrials.gov/ct2/show/NCT04497922.

Development and Testing of an Electronic Health Record-Integrated Patient-Reported Outcome Application and Intervention to Improve Efficiency of Rheumatoid Arthritis Care.

OBJECTIVE: Many patients with rheumatoid arthritis (RA) have difficulty finding clinicians to treat them because of workforce shortages. We developed an app to address this problem by improving care efficiency. The app collects patient-reported outcomes (PROs) and can be used to inform visit timing, potentially reducing the volume of low-value visits. We describe the development process, intervention design, and planned study for testing the app. METHODS: We employed user-centered design, interviewing patients and clinicians, to develop the app. To improve visit efficiency, symptom tracking logic alerts clinicians to PRO trends: worsening PROs generate alerts suggesting an earlier visit, and stable or improving PROs generate notifications that scheduled visits could be delayed. An interrupted time-series analysis with a nonrandomized control population will allow assessment of the impact of the app on visit frequency. RESULTS: Patient interviews identified several of the following needs for effective app and intervention design: the importance of a simple user interface facilitating rapid answering of PROs, the availability of condensed summary information with links to more in-depth answers to common questions regarding RA, and the need for clinicians to discuss the PRO data during visits with patients. Clinician interviews identified the following user needs: PRO data must be easy to view and use during the clinical workflow, and there should be reduced interval visits when PROs are trending worse. Some clinicians believed visits could be delayed for patients with stable PROs, whereas others raised concerns. CONCLUSION: PRO apps may improve care efficiency in rheumatology. Formal evaluation of an integrated PRO RA app is forthcoming.

Real-World Analysis of Off-Label Use of Molecularly Targeted Therapy in a Large Academic Medical Center Cohort.

PURPOSE: The primary objective of this study is to quantify the use of off-label molecularly targeted therapy and describe the clinical situations in which off-label targeted therapy are used. A key secondary objective is to report the outcomes of patients treated with off-label use of targeted therapy. PATIENTS AND METHODS: We searched the electronic health record between 2000 and 2020 at our center to characterize the volume, clinical settings, and outcomes associated with off-label use of targeted therapies in different types of solid tumors. RESULTS: Among 46,712 patients who received targeted therapies, we identified 119 instances of off-label use of targeted therapy. Colon cancer was the most common cancer type to receive off-label targeted therapy in 18 patients (15.1%), followed by 13 with non-small-cell lung cancer (10.9%), eight with cholangiocarcinoma (6.7%), and seven with glioblastoma (5.9%). The most frequent molecular rationale for off-label therapy came from a comprehensive next-generation sequencing test (53.7%). The most frequently mutated gene that provided the rationale for targeted therapy was BRAF (20.1%), with BRAFV600E being the most common molecular alteration overall (15.1%). The median duration of off-label targeted therapy was 3.58 months, and the overall survival of treated patients was 7.59 months. There were 37 patients (31.1%) treated for longer than 6 months, 23 patients (19.3%) who survived ≥ 2 years, and 13 patients who were still on therapy as of June 2020. CONCLUSION: In this large cohort study of patients with solid tumors, off-label use of targeted therapy was uncommon. With that said, a notable proportion of patients had treatment durations ≥ 6 months and survivals of ≥ 2 years.

Assessing Patient Experience and Orientation in the Emergency Department with Virtual Windows.

Patients have benefitted from increasingly sophisticated diagnostic and therapeutic innovations over the years. However, the design of the physical hospital environment has garnered less attention. This may negatively impact a patient's experience and health. In areas of the hospital, such as the emergency department (ED), patients may spend hours, or even days, in a windowless environment. Studies have highlighted the importance of natural light and imagery, as they are essential in providing important stimuli to regulate circadian rhythm and orientation, and to mitigate the onset of certain medical conditions. In hospital locations where standard windows may be infeasible, the use of a virtual window may simulate the benefits of an actual window. In this pilot study, we assessed patient experience and orientation with virtual windows in the ED. We demonstrated that virtual windows are an acceptable technology that may improve patient experience and orientation.

Deploying digital health tools within large, complex health systems: key considerations for adoption and implementation.

In recent years, the number of digital health tools with the potential to significantly improve delivery of healthcare services has grown tremendously. However, the use of these tools in large, complex health systems remains comparatively limited. The adoption and implementation of digital health tools at an enterprise level is a challenge; few strategies exist to help tools cross the chasm from clinical validation to integration within the workflows of a large health system. Many previously proposed frameworks for digital health implementation are difficult to operationalize in these dynamic organizations. In this piece, we put forth nine dimensions along which clinically validated digital health tools should be examined by health systems prior to adoption, and propose strategies for selecting digital health tools and planning for implementation in this setting. By evaluating prospective tools along these dimensions, health systems can evaluate which existing digital health solutions are worthy of adoption, ensure they have sufficient resources for deployment and long-term use, and devise a strategic plan for implementation.

Coronavirus disease 2019 (COVID-19) screening system utilizing daily symptom attestation helps identify hospital employees who should be tested to protect patients and coworkers.

OBJECTIVE: To investigate the effectiveness of a daily attestation system used by employees of a multi-institutional academic medical center, which comprised of symptom-screening, self-referrals to the Occupational Health Services team, and/or a severe acute respiratory coronavirus virus 2 (SARS-CoV-2) test. DESIGN: We conducted a retrospective cohort study of all employee attestations and SARS-CoV-2 tests performed between March and June 2020. SETTING: A large multi-institutional academic medical center, including both inpatient and ambulatory settings. PARTICIPANTS: All employees who worked at the study site. METHODS: Data were combined from the attestation system (COVIDPass), the employee database, and the electronic health records and were analyzed using descriptive statistics including χ2, Wilcoxon, and Kruskal-Wallis tests. We investigated whether an association existed between symptomatic attestations by the employees and the employee testing positive for SARS-CoV-2. RESULTS: After data linkage and cleaning, there were 2,117,298 attestations submitted by 65,422 employees between March and June 2020. Most attestations were asymptomatic (99.9%). The most commonly reported symptoms were sore throat (n = 910), runny nose (n = 637), and cough (n = 570). Among the 2,026 employees who ever attested that they were symptomatic, 905 employees were tested within 14 days of a symptomatic attestation, and 114 (13%) of these tests were positive. The most common symptoms associated with a positive SARS-CoV-2 test were anosmia (23% vs 4%) and fever (46% vs 19%). CONCLUSIONS: Daily symptom attestations among healthcare workers identified a handful of employees with COVID-19. Although the number of positive tests was low, attestations may help keep unwell employees off campus to prevent transmissions.

Symptom monitoring after coronavirus disease 2019 (COVID-19) vaccination in a large integrated healthcare system: Separating symptoms from severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection.

OBJECTIVE: To describe the incidence of systemic overlap and typical coronavirus disease 2019 (COVID-19) symptoms in healthcare personnel (HCP) following COVID-19 vaccination and association of reported symptoms with diagnosis of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection in the context of public health recommendations regarding work exclusion. DESIGN: This prospective cohort study was conducted between December 16, 2020, and March 14, 2021, with HCP who had received at least 1 dose of either the Pfizer-BioNTech or Moderna COVID-19 vaccine. SETTING: Large healthcare system in New England. INTERVENTIONS: HCP were prompted to complete a symptom survey for 3 days after each vaccination. Reported symptoms generated automated guidance regarding symptom management, SARS-CoV-2 testing requirements, and work restrictions. Overlap symptoms (ie, fever, fatigue, myalgias, arthralgias, or headache) were categorized as either lower or higher severity. Typical COVID-19 symptoms included sore throat, cough, nasal congestion or rhinorrhea, shortness of breath, ageusia and anosmia. RESULTS: Among 64,187 HCP, a postvaccination electronic survey had response rates of 83% after dose 1 and 77% after dose 2. Report of ≥3 lower-severity overlap symptoms, ≥1 higher-severity overlap symptoms, or at least 1 typical COVID-19 symptom after dose 1 was associated with increased likelihood of testing positive. HCP with prior COVID-19 infection were significantly more likely to report severe overlap symptoms after dose 1. CONCLUSIONS: Reported overlap symptoms were common; however, only report of ≥3 low-severity overlap symptoms, at least 1 higher-severity overlap symptom, or any typical COVID-19 symptom were associated with infection. Work-related restrictions for overlap symptoms should be reconsidered.

Acceptance of a computer vision facilitated protocol to measure adherence to face mask use: a single-site, observational cohort study among hospital staff.

OBJECTIVES: Mask adherence continues to be a critical public health measure to prevent transmission of aerosol pathogens, such as SARS-CoV-2. We aimed to develop and deploy a computer vision algorithm to provide real-time feedback of mask wearing among staff in a hospital. DESIGN: Single-site, observational cohort study. SETTING: An urban, academic hospital in Boston, Massachusetts, USA. PARTICIPANTS: We enrolled adult hospital staff entering the hospital at a key ingress point. INTERVENTIONS: Consenting participants entering the hospital were invited to experience the computer vision mask detection system. Key aspects of the detection algorithm and feedback were described to participants, who then completed a quantitative assessment to understand their perceptions and acceptance of interacting with the system to detect their mask adherence. OUTCOME MEASURES: Primary outcomes were willingness to interact with the mask system, and the degree of comfort participants felt in interacting with a public facing computer vision mask algorithm. RESULTS: One hundred and eleven participants with mean age 40 (SD15.5) were enrolled in the study. Males (47.7%) and females (52.3%) were equally represented, and the majority identified as white (N=54, 49%). Most participants (N=97, 87.3%) reported acceptance of the system and most participants (N=84, 75.7%) were accepting of deployment of the system to reinforce mask adherence in public places. One third of participants (N=36) felt that a public facing computer vision system would be an intrusion into personal privacy.Public-facing computer vision software to detect and provide feedback around mask adherence may be acceptable in the hospital setting. Similar systems may be considered for deployment in locations where mask adherence is important.

Association of Self-reported High-Risk Allergy History With Allergy Symptoms After COVID-19 Vaccination.

Importance: Allergic history in individuals with confirmed anaphylaxis to a messenger RNA (mRNA) COVID-19 vaccine is common. However, the risk factors for allergy symptoms after receiving the vaccine are unknown. Objective: To assess the association between self-reported history of high-risk allergy and self-reported allergic reactions after mRNA COVID-19 vaccination of health care employees. Design, Setting, and Participants: This cohort study obtained demographic, medical, and vaccine administration data of employees of Mass General Brigham from the institutional electronic health record. Employees who received at least 1 dose of an mRNA COVID-19 vaccine between December 14, 2020, and February 1, 2021, and who completed at least 1 postvaccination symptom survey in the 3 days after vaccination were included. Exposures: Self-reported history of high-risk allergy, defined as a previous severe allergic reaction to a vaccine, an injectable medication, or other allergen. Main Outcomes and Measures: The primary outcome was 1 or more self-reported allergic reactions in the first 3 days after dose 1 or dose 2 of an mRNA COVID-19 vaccine. Multivariable log binomial regression was used to assess the association between allergic reactions and high-risk allergy status. Results: A total of 52 998 health care employees (mean [SD] age, 42 [14] years; 38 167 women [72.0%]) were included in the cohort, of whom 51 706 (97.6%) received 2 doses of an mRNA COVID-19 vaccine and 474 (0.9%) reported a history of high-risk allergy. Individuals with vs without a history of high-risk allergy reported more allergic reactions after receiving dose 1 or 2 of the vaccine (11.6% [n = 55] vs 4.7% [n = 2461]). In the adjusted model, a history of high-risk allergy was associated with an increased risk of allergic reactions (adjusted relative risk [aRR], 2.46; 95% CI, 1.92-3.16), with risk being highest for hives (aRR, 3.81; 95% CI, 2.33-6.22) and angioedema (aRR, 4.36; 95% CI, 2.52-7.54). Conclusions and Relevance: This cohort study found that self-reported history of high-risk allergy was associated with an increased risk of self-reported allergic reactions within 3 days of mRNA COVID-19 vaccination. However, reported allergy symptoms did not impede the completion of the 2-dose vaccine protocol among a cohort of eligible health care employees, supporting the overall safety of mRNA COVID-19 vaccine.

Electronic Paper Displays in Hospital Operations: Proposal for Deployment and Implementation.

BACKGROUND: Display signage is ubiquitous and essential in hospitals to serve several clerical, operational, and clinical functions, including displaying notices, providing directions, and presenting clinical information. These functions improve efficiency and patient engagement, reduce errors, and enhance the continuity of care. Over time, signage has evolved from analog approaches such as whiteboards and handwritten notices to digital displays such as liquid crystal displays, light emitting diodes, and, now, electronic ink displays. Electronic ink displays are paper-like displays that are not backlit and show content by aligning microencapsulated color beads in response to an applied electric current. Power is only required to generate content and not to retain it. These displays are very readable, with low eye strain; minimize the emission of blue light; require minimal power; and can be driven by several data sources, ranging from virtual servers to electronic health record systems. These attributes make adapting electronic ink displays to hospitals an ideal use case. OBJECTIVE: In this paper, we aimed to outline the use of signage and displays in hospitals with a focus on electronic ink displays. We aimed to assess the advantages and limitations of using these displays in hospitals and outline the various public-facing and patient-facing applications of electronic ink displays. Finally, we aimed to discuss the technological considerations and an implementation framework that must be followed when adopting and deploying electronic ink displays. METHODS: The public-facing applications of electronic ink displays include signage and way-finders, timetables for shared workspaces, and noticeboards and bulletin boards. The clinical display applications may be smaller form factors such as door signs or bedside cards. The larger, ≥40-inch form factors may be used within patient rooms or at clinical command centers as a digital whiteboard to display general information, patient and clinician information, and care plans. In all these applications, such displays could replace analog whiteboards, noticeboards, and even other digital screens. RESULTS: We are conducting pilot research projects to delineate best use cases and practices in adopting electronic ink displays in clinical settings. This will entail liaising with key stakeholders, gathering objective logistical and feasibility data, and, ultimately, quantifying and describing the effect on clinical care and patient satisfaction. CONCLUSIONS: There are several use cases in a clinical setting that may lend themselves perfectly to electronic ink display use. The main considerations to be studied in this adoption are network connectivity, content management, privacy and security robustness, and detailed comparison with existing modalities. Electronic ink displays offer a superior opportunity to future-proof existing practices. There is a need for theoretical considerations and real-world testing to determine if the advantages outweigh the limitations of electronic ink displays.

Virtual Team Rounding: A Cross-Specialty Inpatient Care Staffing Program to Manage COVID-19 Surges.

PROBLEM: The SARS-CoV-2 (COVID-19) pandemic presented numerous challenges to inpatient care, including overtaxed inpatient medicine services, surges in patient censuses, disrupted patient care and educational activities for trainees, underused providers in certain specialties, and personal protective equipment shortages and new requirements for physical distancing. In March 2020, as the COVID-19 surge began, an interdisciplinary group of administrators, providers, and trainees at Brigham and Women's Hospital created an inpatient virtual staffing model called the Virtual Team Rounding Program (VTRP). APPROACH: The conceptual framework guiding VTRP development was rapid-cycle innovation. The VTRP was designed iteratively using feedback from residents, physician assistants, attendings, and administrators from March to June 2020. The VTRP trained and deployed a diverse set of providers across specialties as "virtual rounders" to support inpatient teams by joining and participating in rounds via videoconference and completing documentation tasks during and after rounds. The program was rapidly scaled up from March to June 2020. OUTCOMES: In a survey of inpatient providers at the end of the pilot phase, 10/10 (100%) respondents reported they were getting either "a lot" or "a little" benefit from the VTRP and did not find the addition of the virtual rounder burdensome. During the scaling phase, the program grew to support 24 teams. In a survey at the end of the contraction phase, 117/187 (62.6%) inpatient providers who worked with a virtual rounder felt the rounder saved them time. VTRP leadership collaboratively and iteratively developed best practices for challenges encountered during implementation. NEXT STEPS: Virtual rounding provides a valuable extension of inpatient teams to manage COVID-19 surges. Future work will quantitatively and qualitatively assess the impact of the VTRP on inpatient provider satisfaction and well-being, virtual rounders' experiences, and patient care outcomes.

Landscape Analysis of Oncology Mobile Health Applications.

PURPOSE: More than 325,000 mobile health (mhealth) applications (apps) have been developed. We sought to describe the state of oncology-specific apps and to highlight areas of strength and opportunities for future development. METHODS: We searched for oncology apps in the Apple iOS and Google Play app stores in January 2020. Apps were classified by English language support, date of last update, downloads, intended audience, intended purpose, and developer type. RESULTS: We identified 794 oncology-specific, English language applications; only 257 (32%) met basic recency standards and were considered evaluable. Of evaluable apps, almost half (47%) were found in the Medical Store Category and the majority were free (88%). The most common intended audience was health care professionals (45%), with 28% being geared toward the general public and 27% being intended for patients. The intended function was education for 36%, clinical decision support for 19.5%, and patient support for 18%. Only 23% of education apps and 40% of clinical decision support apps reported any formal app content review process. Web developers created 61.5% of apps, scientific societies created 10%, and hospitals or health care organizations created just 6%. Of 54 studies that used mobile apps in oncology identified by a recent meta-analysis, only two could be matched to commercially available apps from our study, suggesting a substantial divide between investigation and product dissemination. CONCLUSION: Relatively few oncology-related apps exist in the commercial marketplace, up-to-date apps are uncommon, and there is a notable absence of key oncology stakeholders in app development. Meaningful development opportunities exist.

Transmitting Device Identifiers of Implants From the Point of Care to Insurers: A Demonstration Project.

BACKGROUND: For implanted devices, an effective postmarket surveillance system does not exist. For medications, the Food and Drug Administration's Sentinel Initiative plays that role, relying mainly on drug codes in insurance claims. Unique device identifiers (UDIs) could play an analogous role for implants, but there is no mandate for providers to include UDIs in claims or for payers to record them. Objections have been raised to incorporating UDIs into claims based on a potential burden on providers. METHODS: To assess this purported barrier, we modified information systems at 2 provider-payer dyads to allow for the transmission of UDI data from provider to payer. In addition, to illustrate the potential benefit of including device data in claims, we used our data to compare rates of 90-day adverse events after implantation using the electronic health record (EHR) alone with the EHR plus claims. RESULTS: The software system modifications were modest and performed as designed. Moreover, the level of difficulty of their development and implementation was comparable to that associated with a typical new release of an existing system. In addition, our data demonstrated the ability of claims-based data plus EHR data to reveal a larger percentage of postprocedure adverse events than data from EHRs alone. CONCLUSIONS: Modifying information systems to allow for the transmission of UDI data from providers to payers should not impose a substantial burden on either. Implementation of a postmarket surveillance system based on such data in claims will require, however, the development of a system analogous to Sentinel.

Association of Display of Patient Photographs in the Electronic Health Record With Wrong-Patient Order Entry Errors.

Importance: Wrong-patient order entry (WPOE) errors have a high potential for harm; these errors are particularly frequent wherever workflows are complex and multitasking and interruptions are common, such as in the emergency department (ED). Previous research shows that interruptive solutions, such as electronic patient verification forms or alerts, can reduce these types of errors but may be time-consuming and cause alert fatigue. Objective: To evaluate whether the use of noninterruptive display of patient photographs in the banner of the electronic health record (EHR) is associated with a decreased rate of WPOE errors. Design, Setting, and Participants: In this cohort study, data collected as part of care for patients visiting the ED of a large tertiary academic urban hospital in Boston, Massachusetts, between July 1, 2017, and June 31, 2019, were analyzed. Exposures: In a quality improvement initiative, the ED staff encouraged patients to have their photographs taken by informing them of the intended safety impact. Main Outcomes and Measures: The rate of WPOE errors (measured using the retract-and-reorder method) for orders placed when the patient's photograph was displayed in the banner of the EHR vs the rate for patients without a photograph displayed. The primary analysis focused on orders placed in the ED; a secondary analysis included orders placed in any care setting. Results: A total of 2 558 746 orders were placed for 71 851 unique patients (mean [SD] age, 49.2 [19.1] years; 42 677 (59.4%) female; 55 109 (76.7%) non-Hispanic). The risk of WPOE errors was significantly lower when the patient's photograph was displayed in the EHR (odds ratio, 0.72; 95% CI, 0.57-0.89). After this risk was adjusted for potential confounders using multivariable logistic regression, the effect size remained essentially the same (odds ratio, 0.57; 95% CI, 0.52-0.61). Risk of error was significantly lower in patients with higher acuity levels and among patients whose race was documented as White. Conclusions and Relevance: This cohort study suggests that displaying patient photographs in the EHR provides decision support functionality for enhancing patient identification and reducing WPOE errors while being noninterruptive with minimal risk of alert fatigue. Successful implementation of such a program in an ED setting involves a modest financial investment and requires appropriate engagement of patients and staff.