The impact of a point-of-care visual clinical decision support tool on admissions for cellulitis in the University of Maryland medical system.

Introduction: Cellulitis is commonly diagnosed in emergency departments (EDs), yet roughly one third of ED patients admitted for presumed cellulitis have another, usually benign, condition instead (eg, stasis dermatitis). This suggests there is an opportunity to reduce health care resource use through improved diagnosis at the point of care. This study seeks to test whether a clinical decision support (CDS) tool interoperable with the electronic medical record (EMR) can reduce inappropriate hospital admissions and drive more appropriate and accurate care. Methods: This study was a trial of an EMR-interoperable, image-based CDS tool for evaluation of ED patients with suspected cellulitis. At the point of assigning a provisional diagnosis of cellulitis in the EMR, the clinician was randomly prompted to use the CDS. Based on the patient features entered into the CDS by the clinician, the CDS provided the clinician a list of likely diagnoses. The following were recorded: patient demographics, disposition and final diagnosis of patients, and whether antibiotics were prescribed. Logistic regression methods were used to determine the impact of CDS engagement on our primary outcome of admission for cellulitis, adjusted for patient factors. Antibiotic use was a secondary end point. Results: From September 2019 to February 2020 (or 7 months), the CDS tool was deployed in the EMR at 4 major hospitals in the University of Maryland Medical System. There were 1269 encounters for cellulitis during the study period. The engagement with the CDS was low (24.1%, 95/394), but engagement was associated with an absolute reduction in admissions (7.1%, p = 0.03). After adjusting for age greater than 65 years, female sex, non-White race, and private insurance, CDS engagement was associated with a significant reduction of admissions (adjusted OR = 0.62, 95% confidence interval (CI): 0.40-0.97, p = 0.04) and antibiotic use (Adjusted OR = 0.63, 95% CI: 0.40-0.99, p = 0.04). Conclusions: CDS engagement was associated with decreased admissions for cellulitis and decreased antibiotic use in this study, despite low levels of CDS engagement. Further research should examine the impact of CDS engagement in other practice environments and measure longer-term outcomes in patients discharged from the ED.

Scabies: Refine your exam, avoid these diagnostic pitfalls.

Nearly half of all infections are missed when first examined. Attentiveness to specific details, particularly in 3 common scenarios, can help ensure an accurate Dx.

Decision support in dermatology and medicine: history and recent developments.

This article is focused on diagnostic decision support tools and will provide a brief history of clinical decision support (CDS), examine the components of CDS and its associated terminology, and discuss recent developments in the use and application of CDS systems, particularly in the field of dermatology. For this article, we use CDS to mean an interactive system allowing input of patient-specific information and providing customized medical knowledge-based results via automated reasoning, for example, a set of rules and/or an underlying logic, and associations.

Dermatology and HIV/AIDS in Africa.

Human immunodeficiency virus and the acquired immunodeficiency syndrome (HIV/AIDS) have greatly complicated dermatologic disease and the required care in most regions of Africa. Opportunistic infections, ectoparasites, Kaposi sarcoma, and skin manifestations of systemic infections are exceedingly common in patients with HIV/AIDS. Dermatologists have contributed significantly to our knowledge base about HIV/AIDS and have played an important educational role regarding the clinical manifestations historically. Because of the increased burden of skin disease in Africa due to the HIV/AIDS epidemic we must redouble our efforts to provide dermatology education to care providers in Africa. We review the burden of skin disease in Africa, how it relates to HIV/AIDS and global infectious disease, current educational strategies in Africa to address this need, and suggest potential solutions to move these efforts forward.

Diagnostic accuracy in patients admitted to hospitals with cellulitis.

Misdiagnosis of non-infectious conditions such as cellulitis is a common error and can result in unnecessary hospitalization and antibiotic use. We sought to prospectively determine the misdiagnosis rate of cellulitis among hospitalized patients and to determine if a visually-based computerized diagnostic decision support system (VCDDSS, also named VisualDx) could generate an improved differential diagnosis (DDx) for misdiagnosed patients. In two separate institutions, attending dermatologists or infectious disease specialists evaluated all consecutive patients hospitalized for "cellulitis" by the emergency department. Among 145 subjects enrolled, misdiagnosis occurred in 41 (28%) patients. The diagnosis most commonly mistaken as cellulitis was stasis dermatitis (37%). At one center, in cases that were misdiagnosed by the emergency department, the VCDDSS included the correct diagnosis in the DDx more frequently than the admitting team (18/28 cases (64%) compared to 4/28 cases (14%), p=0.0003). These results demonstrate the capability of this VCDDSS to assist primary care physicians with generating a more accurate DDx when confronted with patients presenting with possible skin infections. Misdiagnoses may result in a significant source of healthcare costs and misdiagnosis-related patient harm. Inclusion of decision support tools early in the diagnostic workflow may reduce misdiagnosis and result in more efficient healthcare management.

Eye tracking users of a visual diagnostic clinical decision support system to discover decision-making strategies and to inform user interface design.

Clinical decision support systems (CDSS) assist physicians and other medical professionals in tasks such as differential diagnosis. End users may use different decision-making strategies depending on medical training. Study of eye movements reveals information processing strategies that are executed at a level below consciousness. Eye tracking of student physician assistants and medical residents, while using a visual diagnostic CDSS in diagnostic tasks, showed adoption of distinct strategies and informed recommendations for effective user interface design.

Differential diagnosis of the swollen red eyelid.

The differential diagnosis of eyelid erythema and edema is broad, ranging from benign, self-limiting dermatoses to malignant tumors and vision-threatening infections. A definitive diagnosis usually can be made on physical examination of the eyelid and a careful evaluation of symptoms and exposures. The finding of a swollen red eyelid often signals cellulitis. Orbital cellulitis is a severe infection presenting with proptosis and ophthalmoplegia; it requires hospitalization and intravenous antibiotics to prevent vision loss. Less serious conditions, such as contact dermatitis, atopic dermatitis, and blepharitis, are more common causes of eyelid erythema and edema. These less serious conditions can often be managed with topical corticosteroids and proper eyelid hygiene. They are differentiated on the basis of such clinical clues as time course, presence or absence of irritative symptoms, scaling, and other skin findings. Discrete lid lesions are also important diagnostic indicators. The finding of vesicles, erosions, or crusting may signal a herpes infection. Benign, self-limited eyelid nodules such as hordeola and chalazia often respond to warm compresses, whereas malignancies require surgical excision.

Disparities in dermatology educational resources.

Patients with dark skin can present with morphologic variants, subtle disease presentations, and disease manifestations requiring unique management and therapies. With African Americans, Asians, and Hispanic Americans becoming a significant portion of the population, dermatologists must be able to diagnose and manage skin conditions in people of color. In this study, core dermatology educational sources were examined to determine if they provide dermatologists and trainees with the knowledge base necessary to diagnose and treat skin disease in the ethnic patient. Overall, the coverage of dark skin at national meetings and in photographs in the major dermatology resources is limited and variable. More consistent photographic coverage and textual information describing common and serious skin diseases in people of color should be incorporated into educational resources.

Framework for improved communication: the Dermatology Lexicon Project.

A standardized dermatology vocabulary is central to our collective ability to gather clinical information consistently for patient care, to retrieve information for research or disease management, as well as to conduct outcomes analysis for quality improvement. The deficiencies of current classifications have been recognized by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) in their decision to fund the development of a standard complete reference terminology for dermatology. The Dermatology Lexicon will have a major impact both on clinical care and on dermatologic research. Accuracy in medical records and telemedicine communications will be improved. Reliable terminology will provide for more complete and consistent documentation and data aggregation and reporting. In order to create a useful, sustainable lexicon, involvement of the dermatology community is essential.

Medical and dermatology dictionaries: an examination of unstructured definitions and a proposal for the future.

Medical dictionaries serve to describe and clarify the term set used by medical professionals. In this commentary, we analyze a representative set of skin disease definitions from 2 prominent medical dictionaries, Stedman's Medical Dictionary and Dorland's Illustrated Medical Dictionary. We find that there is an apparent lack of stylistic standards with regard to content and form. We advocate a new standard form for the definition of medical terminology, a standard to complement the easy-to-read yet unstructured style of the traditional dictionary entry. This new form offers a reproducible structure, paving the way for the development of a computer readable "dictionary" of medical terminology. Such a dictionary offers immediate update capability and a fundamental improvement in the ability to search for relationships between terms.