To estimate the positive predictive value (PPV) of International Classification of Diseases, Tenth Revision (ICD-10) code U07.1, COVID-19 virus identified, in the Department of Veterans of Affairs ...(VA).
Records of ICD-10 code U07.1 from inpatient, outpatient, and emergency/urgent care settings were extracted from VA medical record data from 4/01/2020 to 3/31/2021. A weighted, random sample of 1500 records from each quarter of the one-year observation period was reviewed by study personnel to confirm active COVID-19 infection at the time of diagnosis and classify reasons for false positive records. PPV was estimated overall and compared across clinical setting and quarters.
We identified 664,406 records of U07.1. Among the 1500 reviewed, 237 were false positives (PPV: 84.2%, 95% CI: 82.4-86.0). PPV ranged from 77.7% in outpatient settings to 93.8% in inpatient settings and was 83.3% in quarter 1, 80.5% in quarter 2, 86.1% in quarter 3, and 83.6% in quarter 4. The most common reasons for false positive records were history of COVID-19 (44.3%) and orders for laboratory tests (21.5%).
The PPV of ICD-10 code U07.1 is low, especially in outpatient settings. Directed training may improve accuracy of coding to levels that are deemed adequate for future use in surveillance efforts.
Background Electronic health records (EHRs) have been identified as a key tool for quality improvement (QI) in health care. However, EHR data must be of sufficient quality to support QI efforts. In ...2005, the Department of Veterans Affairs (VA) began using a novel EHR tool—the CART Program—to support QI in cardiac catheterization laboratories. We evaluated whether data collected by the CART Program were of sufficient quality to support QI. Methods We evaluated the data validity, completeness, and timeliness of CART Program data using a random sample of 200 coronary procedures performed in 10 geographically diverse VA medical centers. Results Of 1690 observations in the CART Program data repository, 1664 (98.5%) were valid, as compared to the VA medical record. The CART Program reports were more complete than cardiac catheterization laboratory reports generated prior to CART Program implementation (79% vs. 63.1%, P < .001). Finally, there was a trend toward earlier availability of completed procedure reports to treating providers after CART Program implementation, with 75% of CART Program reports available within 1 day compared to 4 days for reports generated prior to CART Program implementation ( P = .06). Conclusions Cardiac catheterization reports generated by the VA's CART Program demonstrate excellent data validity, superior completeness, and a trend toward more timely availability to referring providers relative to cardiac catheterization laboratory reports generated prior to CART Program implementation. This demonstration of data quality is a key step in realizing CART Program's aim of supporting QI efforts in VA catheter laboratories.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Despite impressive success of machine learning algorithms in clinical natural language processing (cNLP), rule-based approaches still have a prominent role. In this paper, we introduce medspaCy, an ...extensible, open-source cNLP library based on spaCy framework that allows flexible integration of rule-based and machine learning-based algorithms adapted to clinical text. MedspaCy includes a variety of components that meet common cNLP needs such as context analysis and mapping to standard terminologies. By utilizing spaCy's clear and easy-to-use conventions, medspaCy enables development of custom pipelines that integrate easily with other spaCy-based modules. Our toolkit includes several core components and facilitates rapid development of pipelines for clinical text.
The VA Cardiovascular Assessment, Reporting, and Tracking (CART) system is a customized electronic medical record system which provides standardized report generation for cardiac catheterization ...procedures, serves as a national data repository, and is the centerpiece of a national quality improvement program. Like many health information technology projects, CART implementation did not proceed without some barriers and resistance. We describe the nationwide implementation of CART at the 77 VA hospitals which perform cardiac catheterizations in three phases: (1) strategic collaborations; (2) installation; and (3) adoption. Throughout implementation, success required a careful balance of technical, clinical, and organizational factors. We offer strategies developed through CART implementation which are broadly applicable to technology projects aimed at improving the quality, reliability, and efficiency of health care.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background: Timely identification and reporting of medical device problems is critical to postmarket device surveillance programs to maximize patient safety. Cardiac catheterization laboratories are ...high-device utilization areas well suited for device surveillance. Objective: To demonstrate the feasibility of the national VA Clinical Assessment, Reporting, and Tracking (CART) system, embedded in the electronic health record of all 76 VA cardiac catheterization laboratories, to document unexpected problems with medical devices at the point of care. Methods: We evaluated 260,258 consecutive cardiac catheterization and/or percutaneous coronary intervention procedures on 175,098 Veterans between August 2006 and February 2012. Unexpected device problems (UDPs) encountered for any equipment used during a procedure were entered by clinicians at the point of care as part of regular care documentation. All UDPs were reviewed in collaboration with the FDA to ascertain the likelihood of a device defect (eg, in manufacture or design) and/or contributing to a procedural complication (level I, unlikely; level II, possibly; level III, likely). Results: Of the 260,258 procedure reports, 974 (0.37%) UDP's were reported by 71 (92.2%) of the 76 VA hospitals. After triage, 739 (75.9%) were deemed level I, 196 (20.1%) level II, and 39 (4.0%) level III. Of the 39 level III reports, 12 (30.7%) are in the submission phase as a FDA MedWatch report. The number of monthly UDP reports increased significantly from 2006 to 2012 (P < 0.001). Conclusions: Leveraging a clinical application embedded in the electronic health record and in collaboration with FDA, a proactive national cardiac device surveillance program has been successfully implemented in the VA.
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BFBNIB, CMK, INZLJ, NMLJ, NUK, PNG, UL, UM, UPUK, ZRSKP
Objective: The purpose of this project was to evaluate the informed consent process for donation to a public umbilical cord blood bank. Study Design: Telephone interviews were conducted with 170 ...women who had given consent to donate their newborn infants' umbilical cord blood. Results: Of the 170 women who were contacted, 96.8% of the women reported that all their questions had been answered. Nevertheless, approximately one third of the respondents did not consider themselves to be in research, and almost one quarter of the respondents did not know how to contact the umbilical cord blood bank if they or their infant became seriously ill. Further, a substantial proportion of the respondents did not understand the full range of alternatives to donation and incorrectly endorsed potential benefits. Conclusion: Informed consent could be optimized by (1) having those personnel who obtain consent emphasize that banking involves research and to explain the true benefits of donation, (2) ensuring that parents know how and when to contact the umbilical cord blood bank after donation, and (3) using phone surveys to continue assessments and to monitor changes in the process. (Am J Obstet Gynecol 2002;187:1642-6.)
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
To examine access to and utilization of primary healthcare services with respect to gender. Greater family and child-rearing responsibilities are possible barriers to healthcare access and ...utilization for women with HIV infection.
This study was part of a prospective, randomized, controlled trial evaluating primary care for HIV-infected patients at Duke University Medical Center (DUMC), a tertiary care medical center. Subjects were 214 HIV-infected, uninsured or publicly insured participants. Ambulatory care visits, emergency room utilization, hospitalization rates, length of stay, preventive and screening measures, and antiretroviral use were the outcome measures.
Women (n = 83) and men (n = 131) enrolled in the study were similar with respect to race, educational level, marital status, and employment status. Women with HIV were more likely than men to have children (80% vs. 25%, p = 0.001) and spend their time as primary caregivers for their children (22% vs. 0.8%, p = 0.001). Women had higher CD4(+) cell counts (378 +/- 287 vs. 243 +/- 252 cells/microl, p = 0.0002), and a smaller proportion of women than men had AIDS at baseline (41% vs. 62%, p = 0.002). Women and men had similar numbers of primary care visits, emergency room visits, annual admission rates, and lengths of stay for hospitalizations. Pneumocystis carinii pneumonia prophylaxis, pneumococcal vaccination, and tuberculosis screening were also similar between women and men. Women were more likely than men to have ever been prescribed an antiretroviral agent (88.0% vs. 71.8%, p = 0.005).
Women had greater familial responsibilities than men, but this was not a barrier to access or utilization of healthcare services. Despite less advanced HIV disease, women received similar care and had similar utilization of health services.
To measure the impact of a teaching intervention and to compare process and outcomes of care for HIV-infected patients randomly assigned to a general medicine clinic (GMC) or an infectious disease ...clinic (IDC) for primary care.
Prospective, randomized, controlled trial.
University hospital in Durham, NC.
Two hundred fourteen consecutive HIV-infected patients presenting for primary care.
Physicians at the GMC received HIV-related training and evidence-based practice guidelines.
Utilization of services, health-related quality of life, preventive and screening measures, and antiretroviral use for one year.
At baseline GMC patients were more likely to be African American (85% vs 71%; P =.03) and had lower baseline CD4+ cell counts than IDC patients (262 +/- 269 vs 329 +/- 275; P =.05). A similar and high proportion of patients in both groups received appropriate preventive care services including Pneumocystis carinii pneumonia (PCP) prophylaxis, pneumococcal vaccination, and antiretroviral therapy. Screening for TB was more frequent in GMC (89% vs 68%; P =.001). In the year following randomization, GMC patients made more visits to the emergency department than IDC patients (1.6 +/- 3.0 vs 0.7 +/- 1.5; P =.05). Hospital use was higher for GMC patients with average length of stay 7.8 +/- 6.3 days compared to 5.7 +/- 3.8 days for IDC patients (P =.01). In analyses, which adjust for potential baseline imbalances, these differences remained.
Targeted education in GMC achieved similar provision of primary care for GMC patients, yet use of health care services was higher for this group. The delivery of adequate primary care is necessary but not sufficient to produce changes in health care utilization.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Abstract only Background. Despite growing availability of electronic health records (EHR) and interest in using health IT (HIT) applications within EHR’s to support clinical care, little is know ...about the factors associated with successful implementation of HIT applications. We evaluated the national implementation of the VA Clinical Assessment, Reporting and Tracking (CART) HIT system. Methods. The VA CART system is a clinical application embedded in the VA’s EHR that supports point of care procedure reports based on American College of Cardiology data standards, device surveillance, and real-time national quality of care oversight. CART was successfully implemented at the 75 VA cardiac catheterization hospitals, and remains in full clinical use for all sites. We evaluated the overall time for implementation and the four consecutive stages in the process (Initiation, Installation, Training, Clinical Use). We used Cox Proportional Hazards regression to evaluate the associations between full implementation time and urban location, academic affiliation, geographic region, size, and whether implementation was initiated before or after a memo of senior leadership support was issued. Results. CART was implemented at the 75 VA hospitals over 6.25 years, with a pattern of diffusion typical for successful HIT implementation based on prior studies (Figure 1). Median time per site for implementation was 14 ± 17 months (IQR 7, 33). Initiation, Installation, and Training stages exhibited relatively little variability in duration per site (Md = 2 ± 9, 4 ± 7, 2 ± 6 mos), while there was higher variability in the time required for full Clinical Use (5 ± 11; IQR 2, 14). In multivariable analysis, sites that initiated implementation after the senior leadership statement had significantly faster implementation (HR 0.49, 95% CI 0.29-0.83, P=0.008). Conclusions. The CART system was successfully implemented nationwide, achieving full use in the 75 VA cardiac cath labs. The final stage, full Clinical Use, took the longest and was most variable by site. These results reinforce that successful HIT implementation does not end with technical installation and training, and must support clinical use as part of routine care delivery. Our results also reinforce the importance of senior leadership support for HIT implementation to support clinical care. Unable to Display Character:
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