Publications by authors named "Evan Orenstein"

Background: Engagement of clinicians who understand clinical workflows and technology constraints can accelerate the development and implementation of better electronic health record (EHR) designs that improve quality and reduce burnout. Provider builder programs can accelerate clinical informatics education for a broader coalition of clinical specialties.

Objective: In this State of the Art / Best Practice paper, we aim to (1) propose a provider builder maturity model informed by the experience of three institutions using a single EHR vendor (Epic Systems©) and (2) describe the program elements and relationships necessary to advance along this model to yield organizational benefits.

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  • Clinical Decision Support (CDS) tools struggle with effectiveness due to poor usability and alignment with clinical workflows, highlighting the need for usability testing across all CDS implementations instead of just selected projects.
  • The paper discusses challenges in scaling usability testing in healthcare operations and proposes "guerilla in-situ usability testing," based on hands-on experience from over 20 projects in a year, as a practical solution.
  • While some rigor in methodology was relaxed for quicker implementation, the positive impacts of user feedback and design improvements suggest that broader use of usability testing could significantly enhance CDS effectiveness and health outcomes.
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  • * Previous efforts to tackle PIVIE have centered on creating workflow bundles and evidence-based guidelines.
  • * This project demonstrated that Clinical Decision Support systems, through interruptive alerts, can enhance the identification and treatment of severe PIVIE by promoting more vascular access team consultations.
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  • Many Electronic Health Record (EHR) systems still rely on paper processes due to complex workflows where multiple stakeholders are involved over time.
  • The study focuses on improving the Latent Tuberculosis Infection (LTBI) testing workflow by analyzing and replacing the paper process, resulting in a significant increase in timely documentation of Tuberculin Skin Tests (TST).
  • By applying human-centered design practices and automating certain steps, the new electronic workflow not only enhanced documentation rates (from 57% to 95%) but also proved to be implementable with limited resources, making it more efficient for clinical settings.
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  • General pediatric providers often feel unprepared to discuss new guidelines for early peanut introduction due to rapidly changing recommendations.
  • A clinical decision support (CDS) tool was developed, tested, and implemented to enhance conversations about peanut introduction during well-child checkups (WCCs).
  • After using the CDS tool, pediatric providers showed a significant increase in awareness and comfort regarding peanut guidelines, leading to a substantial rise in discussions and plans for peanut introduction among families during WCCs.
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Background: Wrong-patient order entry (WPOE) is a potentially dangerous medical error. It remains unknown if patient photographs reduce WPOE in the pediatric inpatient population.

Materials And Methods: Order sessions from a single pediatric hospital system were examined for retract-and-reorder (RAR) events, a surrogate WPOE measure.

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  • * A multidisciplinary team redesigned the order set using feedback from real clinical users during iterative usability testing.
  • * The testing resulted in design changes that significantly reduced error rates, demonstrating the importance of early usability testing in preventing future mistakes.
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  • Numerous programs exist to address clinical decision support (CDS) issues, specifically focusing on reducing the frustrating number of alerts and their burden on hospital staff, which can be hard to implement universally in different healthcare systems.
  • The study aimed to reduce the alert burden for nurses through a targeted quality-improvement strategy, focusing on the most frequent alerts that took up significant nursing time monthly.
  • Following the interventions, there was a significant 58% reduction in alert firings, more actions taken on alerts, and a decrease in time nurses spent resolving these alerts, indicating a successful reduction in alert fatigue.
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  • The study aimed to develop automated tools for actively monitoring errors in pediatric blood management (PBM) rather than relying on passive methods.
  • An expert panel identified 28 triggers for errors, leading to the creation of 5 automated tools, which were tested using electronic health record data over four years.
  • Findings showed that first transfusions without patient identification were common near misses, and over-transfusions were identified as a significant source of harm in pediatric care.
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Pediatric hospitalists frequently interact with clinical decision support (CDS) tools in patient care and use these tools for quality improvement or research. In this method/ology paper, we provide an introduction and practical approach to developing and evaluating CDS tools within the electronic health record. First, we define CDS and describe the types of CDS interventions that exist.

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Objective: To assess the relationship between the Child Opportunity Index (COI), a comprehensive measurement of social determinants of health, and specific COI domains on patient-specific outcomes following congenital cardiac surgery in the metropolitan region of Atlanta, Georgia.

Study Design: In this retrospective chart review, we included patients who underwent an index operation for congenital heart disease between 2010 and 2020 in a single pediatric health care system. Patients' addresses were geocoded and mapped to census tracts.

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  • Children are at higher risk for medication-related issues due to errors in weight-based dosing, prompting a study to reduce dosing errors by keeping recorded and dosing weights aligned.
  • The study used in-situ usability testing to create a clinical decision support system that alerts healthcare providers to update a child's weight if it's significantly different from the last recorded weight.
  • As a result of the intervention, the occurrence of medication dosing errors based on weight decreased significantly, showing that user-centered design can enhance medication safety without overwhelming clinicians with alerts.
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Background: Childhood-onset systemic lupus erythematosus (cSLE) is an autoimmune disease with variable disease expression but noted association with significant disease-related damage, morbidity, and mortality. The European Alliance of Associations for Rheumatology (EULAR) recommends routine monitoring of SLE through validated disease activity and chronicity indices, including the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). Despite this, physician adherence with SLEDAI documentation remains elusive at various academic institutions.

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Background: Asthma is a common cause of morbidity and mortality in children. Predictive models may help providers tailor asthma therapies to an individual's exacerbation risk. The effectiveness of asthma risk scores on provider behavior and pediatric asthma outcomes remains unknown.

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Background: Peanut allergy has recently become more prevalent. Peanut introduction recommendations have evolved from suggesting peanut avoidance until the age of 3 years to more recent guidelines encouraging early peanut introduction after the Learning Early about Peanut Allergy (LEAP) study in 2015. Guideline adherence is poor, leading to missed care opportunities.

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Rituximab, used in the treatment of some rheumatic and kidney diseases, can lead to hepatitis B virus (HBV) reactivation; HBV screening is recommended for those starting this medication. We aimed to improve by 50% the proportion of patients undergoing HBV screening by implementing multimodal interventions to support clinicians in this evidence-based practice. We conducted a quality improvement project from November 2020 to June 2022 at a tertiary care pediatric hospital system, including patients with rheumatic and/or kidney diseases starting rituximab.

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Unlabelled: Hospitalized children experience frequent sleep disruptions. We aimed to reduce caregiver-reported sleep disruptions of children hospitalized on the pediatric hospital medicine service by 10% over 12 months.

Methods: In family surveys, caregivers cited overnight vital signs (VS) as a primary contributor to sleep disruption.

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  • * A study analyzed sexual history documentation and STI testing rates among 2242 adolescents (ages 14-19) admitted to a pediatric hospital between 2017-2019, revealing SHxD rates of 40.9% and STI testing rates of 17.2%.
  • * Key factors like patient gender, race, and physician involvement influenced the likelihood of sexual history documentation and STI testing, while chlamydia was found to be the most common STI among those tested.
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Background: Clinical practice guidelines (CPGs) and associated order sets can help standardize patient care and lead to higher-value patient care. However, difficult access and poor usability of these order sets can result in lower use rates and reduce the CPGs' impact on clinical outcomes. At our institution, we identified multiple CPGs for general pediatrics admissions where the appropriate order set was used in <50% of eligible encounters, leading to decreased adoption of CPG recommendations.

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Background: The Pediatric Emergency Care Applied Research Network (PECARN) prediction rule identifies febrile infants at low risk for serious bacterial infection (SBI). However, its impact on avoidable interventions in the emergency department remains unknown.

Objective: To study the impact on lumbar puncture (LP) performance, empiric antibiotic use, and admissions after implementing a febrile infant clinical practice guideline for infants aged 29 to 60 days based on the PECARN prediction rule in the pediatric emergency department.

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Background: Influenza causes greater morbidity in children with cancer or sickle cell disease (SCD). Literature on influenza vaccination receipt for these populations is limited in low-vaccination states. Outpatient interventions improve vaccine receipt but isolated inpatient interventions remain unstudied.

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Background: We aimed to develop and validate a rule-based Natural Language Processing (NLP) algorithm to detect sexual history documentation and its five key components [partners, practices, past history of sexually transmitted infections (STIs), protection from STIs, and prevention of pregnancy] among adolescent encounters in the pediatric emergency and inpatient settings.

Methods: We iteratively designed a NLP algorithm using pediatric emergency department (ED) provider notes from adolescent ED visits with specific abdominal or genitourinary (GU) chief complaints. The algorithm is composed of regular expressions identifying commonly used phrases in sexual history documentation.

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Background: Hospitalized children with central venous lines (CVLs) are at higher risk of hospital-acquired infections. Information in electronic health records (EHRs) can be employed in training deep learning models to predict the onset of these infections. We incorporated clinical notes in addition to structured EHR data to predict serious bloodstream infections, defined as positive blood culture followed by at least 4 days of new antimicrobial agent administration, among hospitalized children with CVLs.

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  • Every healthcare interaction with children is a chance to deliver both immediate care and ongoing health support.
  • A Clinical Decision Support (CDS) system was launched in a specialized pediatric hospital to boost influenza vaccination rates among eligible children during the 2019-2020 flu season.
  • The study investigates the reasons behind the low vaccine uptake despite the CDS implementation and seeks potential solutions to enhance flu vaccine coverage.
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  • Interruptive clinical decision support systems can provide valuable alerts in healthcare, but their use must be balanced to avoid alert fatigue among medical professionals.
  • This review highlights effective strategies for managing these alerts, ensuring they remain useful rather than overwhelming.
  • It emphasizes the need for a comprehensive understanding of the entire alerting ecosystem, not just those within electronic health records, to enhance decision-making and governance in medical practice.
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