BACKGROUND: The OpenNotes initiative launched an international movement aimed at making health care more transparent by improving communication with, and access to, information for patients through provider note sharing. Little has been written either on provider note sharing in pediatric and adolescent populations or on the impact of system default settings versus voluntary provider note sharing. OBJECTIVE: We describe our journey as a pediatric integrated delivery network to default share notes in ambulatory specialty practices not only with parent proxies but also with teens and discuss the methods that led to a successful implementation. METHODS: Retrospective analysis of every ambulatory shareable medical provider note written in pediatric subspecialty clinics within an integrated pediatric delivery network from April 2017 through March 2019. RESULTS: From April 2017 to February 2018, a total of 221,655 notes were shareable based on organizational policies, yet only 224 (0.1%) were actually shared with patients and families. After implementing a system of default release of notes from March 2018 to January 2019, a total of 224,960 notes were shareable, of which 191,379 (85%) were shared. CONCLUSION: Requiring providers to take an action to share notes (opt-in) results in few notes being shared while requiring providers to take an action to not share notes (opt-out) results in high levels of note sharing. We demonstrate that default release of notes in pediatric organizations to both proxies and teens is not only achievable but also likely to lead to increased provider note sharing with patients without obvious negative impact on providers or the organization.

Background

The OpenNotes initiative launched an international movement aimed at making health care more transparent by improving communication with, and access to, information for patients through provider note sharing. Little has been written either on provider note sharing in pediatric and adolescent populations or on the impact of system default settings versus voluntary provider note sharing.

Objective

We describe our journey as a pediatric integrated delivery network to default share notes in ambulatory specialty practices not only with parent proxies but also with teens and discuss the methods that led to a successful implementation.

Methods

Retrospective analysis of every ambulatory shareable medical provider note written in pediatric subspecialty clinics within an integrated pediatric delivery network from April 2017 through March 2019.

Results

From April 2017 to February 2018, a total of 221,655 notes were shareable based on organizational policies, yet only 224 (0.1%) were actually shared with patients and families. After implementing a system of default release of notes from March 2018 to January 2019, a total of 224,960 notes were shareable, of which 191,379 (85%) were shared.

Conclusion

Requiring providers to take an action to share notes (opt-in) results in few notes being shared while requiring providers to take an action to not share notes (opt-out) results in high levels of note sharing. We demonstrate that default release of notes in pediatric organizations to both proxies and teens is not only achievable but also likely to lead to increased provider note sharing with patients without obvious negative impact on providers or the organization.

OBJECTIVE: The authors describe a novel solution to the challenges of lengthy notes and poor note readability by creating an unobtrusive clinical decision support tool named disappearing help text. METHODS: We designed this tool in Pediatric Hospital Medicine (PHM) note templates to provide in-line decision support on best documentation practices, note bloat reduction, billing compliance, and provider workflow enhancement. RESULTS: After template changes that utilized disappearing help text, we reduced the percent of notes utilizing any laboratory SmartLink from 90.2 to 15.3% for admission notes (p <0.001), 92.6 to 17.8% for progress notes (p <0.001), and 14 to 7.2% for discharge summaries (p <0.001). In admission and progress notes, this correlated with a significant reduction in the median note length as a proxy of note bloat reduction, with a 18.7% character count reduction in progress notes (p <0.001) and a 6.4% reduction in admission notes (p <0.001). PHM coding queries decreased from an average of 42 per month to 36 per month, and there was no change in PHM attending billing compliance audit performance. DISCUSSION: Note template changes that utilized disappearing help text significantly reduced the length of both progress and admission notes, a proxy for note bloat reduction, without negatively impacting coding query frequency or internal billing audit performance. One factor that likely contributed to this reduction in note length is the reduced usage of laboratory SmartLinks prompted by disappearing help text. CONCLUSION: We present the use of in-line disappearing help text embedded into note templates as a clinical decision support tool to improve note readability, educate trainees on note documentation, and protect confidential teen information. Help text implementation correlated with a reduction in the automatic insertion of laboratories into notes and a decrease in note character count.

The Epic electronic health record (EHR) platform supports structured data entry systems (SDES), which allow developers, with input from users, to create highly customized patient-record templates in order to maximize data completeness and to standardize structure. There are many potential advantages of using discrete data fields in the EHR to capture data for secondary analysis and epidemiological research, but direct data acquisition from clinicians remains one of the largest obstacles to leveraging the EHR for secondary use. Physician resistance to SDES is multifactorial. A 35-item questionnaire based on Unified Theory of Acceptance and Use of Technology, was used to measure attitudes, facilitation, and potential incentives for adopting SDES for clinical documentation among 25 pediatric specialty physicians and surgeons. Statistical analysis included chi-square for categorical data as well as independent sample t-tests and analysis of variance for continuous variables. Mean scores of the nine constructs demonstrated primarily positive physician attitudes toward SDES, while the surgeons were neutral. Those under 40 were more likely to respond that facilitating conditions for structured entry existed as compared to the two older age groups (p = .02). Pediatric surgeons were significantly less positive than specialty physicians about SDES effects on Performance (p = .01) and the effect of Social Influence (p = .02); but in more agreement that use of forms was voluntary (p = .02). Attitudinal differences likely reflect medical training, clinical practice workflows, and division specific practices. Identified resistance indicate efforts to increase SDES adoption should be discipline-targeted rather than a uniform approach.

Objectives

Increase parent/caregiver ability to correctly identify the attending in charge and define terminology of treatment team members (TTMs). We hypothesized that correct TTM identification would increase with use of an electronic communication tool. Secondary aims included assessing subjects' satisfaction with and trust of TTM and interest in computer activities during hospitalization.

Methods

Two similar groups of parents/legal guardians/primary caregivers of children admitted to the Pediatric Hospital Medicine teaching service with an unplanned first admission were surveyed before (Phase 1) and after (Phase 2) implementation of a novel electronic medical record (EMR)-based tool with names, photos, and definitions of TTMs. Physicians were also surveyed only during Phase 1. Surveys assessed TTM identification, satisfaction, trust, and computer use.

Results

More subjects in Phase 2 correctly identified attending physicians by name (71% vs. 28%, P < .001) and correctly defined terms intern, resident, and attending (P ≤ .03) compared with Phase 1. Almost all subjects (>79%) and TTMs (>87%) reported that subjects' ability to identify TTMs moderately or strongly impacted satisfaction and trust. The majority of subjects expressed interest in using computers to understand TTMs in each phase.

Conclusions

Subjects' ability to correctly identify attending physicians and define TTMs was significantly greater for those who used our tool. In our study, subjects reported that TTM identification impacted aspects of the TTM relationship, yet few could correctly identify TTMs before tool use. This pilot study showed early success in engaging subjects with the EMR in the hospital and suggests that families would engage in computer-based activities in this setting.

Introduction

Discharge communication is critical for the continuity of patient care. However, discharge summaries are often not available in time for follow-up visits, and the content is inconsistent. We aimed to decrease the average time to discharge summary completion by 25%, reduce deficiencies (information errors) by 50%, and increase discharge summary template use to >80% in 6 months.

Methods

A pediatric interprofessional team used quality improvement methods to identify barriers and implement interventions, including discharge summary completion time expectation, electronic health record discharge summary template changes addressing gaps, and training. Notable changes to the template included embedded writing tips to guide writers and specific template choices for common diagnoses to standardize content. The primary outcome measure was the mean discharge summary completion time. Secondary measures were the percentage of discharge summaries with deficiencies and the rate of template use.

Results

After interventions, the mean discharge summary completion time decreased by 70% (from 71.5 to 21.8 hours). Discharge summary deficiencies decreased 44% (from 4.5% to 2.5%), and template use increased from 62% to 97%.

Conclusion

Quality improvement methods and a newly designed electronic health record-discharge summary template were used to dramatically improve discharge summary timeliness and standardize content to streamline continuity of care.

Objective

To assess the counts of infant maltreatment-related medical encounters at a large medical system during a 21-month span of the COVID-19 pandemic.

Methods

Retrospective data for this study came from all inpatient and emergency department medical encounters for infants from January 1, 2016, through November 30, 2021, at a single children's hospital system in California. Distributions of medical encounters were tabulated and plotted over time. Interrupted time series models were used to evaluate changes in child maltreatment medical encounters.

Results

Medical encounters for infants with child maltreatment diagnoses increased following the onset of COVID-19. Monthly counts of encounters with indicated maltreatment trended upward following the start of the pandemic. Interrupted time series models showed the count of maltreatment encounters increased 64% with the onset of COVID-19.

Conclusions

We found an increase in infant maltreatment medical encounters during a 21-month period following the onset of COVID-19. These findings suggest that the pandemic may have adversely affected the safety of infants and ongoing work is needed to understand better the pandemic impacts on child maltreatment.

Objectives

To describe the implementation process and assess results of a large-scale universal depression screening program with pathways to suicide risk screening in a pediatric integrated delivery network.

Study design

This retrospective study analyzes depression and suicide risk screening data for 95 613 patients ages 12-17 years.

Results

Of the 95 613 adolescent patients who were screened for depression, 2.4% (2266) screened positive for risk for moderate-severe depression (>10 Patient Health Questionnaire; 9-item version) and 4.1% (3942) endorsed elevated suicide risk (≥1 Columbia Suicide Severity Rating Scale). Overall, 51% of screened patients who present with a primary psychiatric concern screened positive for elevated risk of suicide (2132). Two percent of screened patients who presented with a primary medical concern screened positive for elevated risk of suicide. Nearly one-half (45.9%) of all elevated suicide risk screenings were from patients with a primary medical concern.

Conclusions

A large-scale universal depression screening program with a pathway to identify elevated suicide risk was implemented in a pediatric health care system using the Patient Health Questionnaire and the Columbia Suicide Severity Rating Scale. This screening program identified youth with moderate-severe depression and elevated risk for suicide with and without presenting psychiatric concerns across service settings.

BACKGROUND: Pediatric depression is a global concern that has fueled efforts for enhanced detection and treatment engagement. As one example, the US Preventive Services Task Force recommends depression screening for adolescents ages 12-18 years. While many health systems have implemented components of depression screening protocols, there is limited evidence of effective follow-up for pediatric depression. A key barrier is timely team communication and coordination across clinicians and staff within and across service areas for prompt service linkage. However, team effectiveness interventions have been shown to improve team processes and outcomes and can be applied in healthcare settings. METHODS: This project aims to refine and test a team communication training implementation strategy to improve implementation of an existing pediatric depression screening protocol in a large pediatric healthcare system. The team will be defined as part of the study but is expected to include medical assistants, nurses, physicians, and behavioral health clinicians within and across departments. The implementation strategy will target team mechanisms at the team-level (i.e., intra-organizational alignment and implementation climate) and team member-level (i.e., communication, coordination, psychological safety, and shared cognition). First, the project will use mixed methods to refine the team training strategy to fit the organizational context and workflows. Next, a hybrid type 3 implementation-effectiveness pilot trial will assess the initial effectiveness of the team communication training (implementation strategy) paired with the current universal depression screening protocol (clinical intervention) on implementation outcomes (i.e., feasibility, acceptability, appropriateness, workflow efficiency) and clinical/services outcomes (increased frequency of needed screening and reduced time to service linkage). Finally, the study will assess mechanisms at the team and team member levels that may affect implementation outcomes. DISCUSSION: Team communication training is hypothesized to lead to improved, efficient, and effective decision-making to increase the compliance with depression screening and timely service linkage. Findings are expected to yield better understanding and examples of how to optimize team communication to improve efficiency and effectiveness in the pediatric depression screening-to-treatment cascade. This should also culminate in improved implementation outcomes including patient engagement critical to address the youth mental health crisis. TRIAL REGISTRATION: NCT06527196. Trial Sponsor: University of California San Diego.

Objective

To characterize pre-implementation organizational factors associated with Access To Tailored Autism Integrated Care (ATTAIN), an integrated care model for children with autism and identified or suspected co-occurring mental health needs.

Methods

Pediatric primary care providers (n=36) completed surveys as part of a pilot study testing ATTAIN feasibility. Measures assessed: background characteristics; implementation climate; organizational readiness; evidence-based practice (EBP) attitudes; knowledge, confidence and comfort caring for children with autism.

Results

Compared to providers from a network of primary care practices and an integrated healthcare system, providers from a Federally Qualified Health Center (FQHC) reported less positive perceptions of climate supportive of EBP implementation and, specifically, selection for openness and rewards for EBPs. Implementation climate was associated with autism knowledge, comfort with mental health referral and follow up, and organizational change efficacy.

Conclusions

Findings advance understanding of pre-implementation organizational context factors important to assess for EBP implementation in diverse pediatric care settings.