BACKGROUND: Surveillance of hospital-acquired pressure injuries (HAPI) is often suboptimal when relying on administrative health data, as International Classification of Diseases (ICD) codes are known to have long delays and are undercoded. We leveraged natural language processing (NLP) applications on free-text notes, particularly the inpatient nursing notes, from electronic medical records (EMRs), to more accurately and timely identify HAPIs.
OBJECTIVE: This study aimed to show that EMR-based phenotyping algorithms are more fitted to detect HAPIs than ICD-10-CA algorithms alone, while the clinical logs are recorded with higher accuracy via NLP using nursing notes.
METHODS: Patients with HAPIs were identified from head-to-toe skin assessments in a local tertiary acute care hospital during a clinical trial that took place from 2015 to 2018 in Calgary, Alberta, Canada. Clinical notes documented during the trial were extracted from the EMR database after the linkage with the discharge abstract database. Different combinations of several types of clinical notes were processed by sequential forward selection during the model development. Text classification algorithms for HAPI detection were developed using random forest (RF), extreme gradient boosting (XGBoost), and deep learning models. The classification threshold was tuned to enable the model to achieve similar specificity to an ICD-based phenotyping study. Each model\'s performance was assessed, and comparisons were made between the metrics, including sensitivity, positive predictive value, negative predictive value, and F1-score.
RESULTS: Data from 280 eligible patients were used in this study, among whom 97 patients had HAPIs during the trial. RF was the optimal performing model with a sensitivity of 0.464 (95% CI 0.365-0.563), specificity of 0.984 (95% CI 0.965-1.000), and F1-score of 0.612 (95% CI of 0.473-0.751). The machine learning (ML) model reached higher sensitivity without sacrificing much specificity compared to the previously reported performance of ICD-based algorithms.
CONCLUSIONS: The EMR-based NLP phenotyping algorithms demonstrated improved performance in HAPI case detection over ICD-10-CA codes alone. Daily generated nursing notes in EMRs are a valuable data resource for ML models to accurately detect adverse events. The study contributes to enhancing automated health care quality and safety surveillance.

Healthcare costs in the United States (US) exceed those of comparable nations without yielding better outcomes. Factors contributing to this include lack of cost transparency, limited outpatient resources due to primary care provider shortages, and high patient volumes, where patients are not educated on differentials and the stepwise process of workup. Addressing these issues could curb unnecessary hospitalizations and expenses. A 31-year-old woman with hypertension, alcohol use, anemia, and obesity experienced paresthesias in September 2022. At her first visit, the exam was consistent with decreased bilateral plantar sensation; however, there was no weakness or gait abnormality. This was not consistent with a focal neurologic distribution. Despite multiple ER visits, her condition persisted. Initial evaluations included potassium replacement ($80 for labs, $13 for tablet), nonacute head CT ($1500), and benign CT L-spine ($2500). Subsequent hospitalization led to brain MRI/MRA head/neck ($6700) and serum workup ($240), revealing deficiencies in vitamin D, folate, and B12. Treatment involved prednisone taper ($30) and supplemental vitamins ($35), with lifestyle recommendations ($0). After evaluating CompuNet lab costs and equivalent market imaging prices, potential savings exceeding $15,000 were identified through more focused and cost-conscious initial testing including vitamin studies and outpatient management, reducing hospitalizations and imaging expenses. Rising healthcare costs in the US are driven by various factors, yet fail to correlate with improved outcomes. Our case argues that enhancing access to primary care, promoting cost transparency, and educating patients on healthcare decisions are crucial for mitigating excessive spending.

BACKGROUND. To implement provisions of the 21st Century Cures Act that address information blocking, federal regulations mandated that health systems provide patients with immediate access to elements of their electronic health information, including imaging results. OBJECTIVE. The purpose of this study was to compare patient access of radiology reports before and after implementation of the information-blocking provisions of the 21st Century Cures Act. METHODS. This retrospective study included patients who underwent outpatient imaging examinations from January 1, 2021, through December 31, 2022, at three campuses within a large health system. The system implemented policies to comply with the Cures Act information-blocking provisions on January 1, 2022. Imaging results were released in patient portals after a 36-hour embargo period before implementation versus being released immediately after report finalization after implementation. Data regarding patient report access in the portal and report acknowledgment by the ordering provider in the EMR were extracted and compared between periods. RESULTS. The study included reports for 1,188,692 examinations in 388,921 patients (mean age, 58.5 ± 16.6 [SD] years; 209,589 women, 179,290 men, eight nonbinary individuals, and 34 individuals for whom sex information was missing). A total of 77.5% of reports were accessed by the patient before implementation versus 80.4% after implementation. The median time from report finalization to report release in the patient portal was 36.0 hours before implementation versus 0.4 hours after implementation. The median time from report release to first patient access of the report in the portal was 8.7 hours before implementation versus 3.0 hours after implementation. The median time from report finalization to first patient access was 45.0 hours before implementation versus 5.5 hours after implementation. Before implementation, a total of 18.5% of reports were first accessed by the patient before being accessed by the ordering provider versus 44.0% after implementation. After implementation, the median time from report release to first patient access was 1.8 hours for patients with age younger than 60 years old versus 4.3 hours for patients 60 years old or older. CONCLUSION. After implementation of institutional policies to comply with 21st Century Cures Act information-blocking provisions, the length of time until patients accessed imaging results decreased, and the proportion of patients who accessed their reports before the ordering provider increased. CLINICAL IMPACT. Radiologists should consider mechanisms to ensure timely and appropriate communication of important findings to ordering providers.

UNASSIGNED: Medical notes are narratives that describe the health of the patient in free text format. These notes can be more informative than structured data such as the history of medications or disease conditions. They are routinely collected and can be used to evaluate the patient\'s risk for developing chronic diseases such as dementia. This study investigates different methodologies for transforming routine care notes into dementia risk classifiers and evaluates the generalizability of these classifiers to new patients and new health care institutions.
UNASSIGNED: The notes collected over the relevant history of the patient are lengthy. In this study, TF-ICF is used to select keywords with the highest discriminative ability between at risk dementia patients and healthy controls. The medical notes are then summarized in the form of occurrences of the selected keywords. Two different encodings of the summary are compared. The first encoding consists of the average of the vector embedding of each keyword occurrence as produced by the BERT or Clinical BERT pre-trained language models. The second encoding aggregates the keywords according to UMLS concepts and uses each concept as an exposure variable. For both encodings, misspellings of the selected keywords are also considered in an effort to improve the predictive performance of the classifiers. A neural network is developed over the first encoding and a gradient boosted trees model is applied to the second encoding. Patients from a single health care institution are used to develop all the classifiers which are then evaluated on held-out patients from the same health care institution as well as test patients from two other health care institutions.
UNASSIGNED: The results indicate that it is possible to identify patients at risk for dementia one year ahead of the onset of the disease using medical notes with an AUC of 75% when a gradient boosted trees model is used in conjunction with exposure variables derived from UMLS concepts. However, this performance is not maintained with an embedded feature space and when the classifier is applied to patients from other health care institutions. Moreover, an analysis of the top predictors of the gradient boosted trees model indicates that different features inform the classification depending on whether or not spelling variants of the keywords are included.
UNASSIGNED: The present study demonstrates that medical notes can enable risk prediction models for complex chronic diseases such as dementia. However, additional research efforts are needed to improve the generalizability of these models. These efforts should take into consideration the length and localization of the medical notes; the availability of sufficient training data for each disease condition; and the variabilities resulting from different feature engineering techniques.

Recurrent pregnancy loss (RPL), defined as 2 or more pregnancy losses, affects 5-6% of ever-pregnant individuals. Approximately half of these cases have no identifiable explanation. To generate hypotheses about RPL etiologies, we implemented a case-control study comparing the history of over 1,600 diagnoses between RPL and live-birth patients, leveraging the University of California San Francisco (UCSF) and Stanford University electronic health record databases. In total, our study included 8,496 RPL (UCSF: 3,840, Stanford: 4,656) and 53,278 Control (UCSF: 17,259, Stanford: 36,019) patients. Menstrual abnormalities and infertility-associated diagnoses were significantly positively associated with RPL in both medical centers. Age-stratified analysis revealed that the majority of RPL-associated diagnoses had higher odds ratios for patients <35 compared with 35+ patients. While Stanford results were sensitive to control for healthcare utilization, UCSF results were stable across analyses with and without utilization. Intersecting significant results between medical centers was an effective filter to identify associations that are robust across center-specific utilization patterns.

UNASSIGNED: There is a global agreement that palliative care should be universally accessible. However, in low- and middle-income countries and conflict zones, most people lack access to it. In the Eastern Mediterranean Region (EMR), no country has achieved integration of palliative care into its health care system, and only 4 countries have better-than-isolated palliative care provision.
UNASSIGNED: To promote and guide palliative care improvement in the EMR, with case studies showing the successes and challenges of palliative care implementation from 4 countries in the Region.
UNASSIGNED: We developed a structured, succinct, case-writing format and invited palliative care leaders in the EMR to use it to describe successes and challenges in palliative care implementation in their countries.
UNASSIGNED: Within the EMR, in addition to many challenges and needs, there are examples of successful palliative care policy development, community-based service creation, and paediatric palliative care implementation.
UNASSIGNED: The experiences of the regional palliative care leaders documented in succinct, structured case studies, can help guide regional palliative care development in the EMR and other regions.
نماذج الرعاية الملطِّفة وأوجه الارتقاء بها في أربعة بلدان بإقليم شرق المتوسط: دراسة حالة.
إيريك كراكاور، سامي عيد الشمري، بالاجي دورايسامي، مريم رسولي، رضا رزق الله، سماهر فاضل، هبة عثمان.
UNASSIGNED: ثمة اتفاق عالمي على أنه ينبغي إتاحة الرعاية الملطِّفة إتاحةً شاملةً عامة. ومع ذلك، يفتقر معظم الناس في البلدان ذات الدخل المنخفض والمتوسط ومناطق الصراع إلى الرعاية الملطِّفة. وما من بلدٍ في إقليم شرق المتوسط قد حقق دمج الرعاية الملطِّفة في نظام الرعاية الصحية فيه، بل إن أربعة بلدان فقط هي التي تقدم رعاية ملطِّفة أفضل من مجرد رعاية العزل.
UNASSIGNED: هدفت هذه الدراسة الى الترويج لتحسين الرعاية الملطِّفة في إقليم شرق المتوسط، ووضع توجُّه وقواعد إرشادية لها، في ضوء دراسات حالة تَعرِض النجاحات والتحديات التي تجابه تنفيذ الرعاية المُلطِّفة في أربعة بلدان في الإقليم.
UNASSIGNED: وضعنا صيغة منظمة وموجزة لصوغ دراسات الحالة، ودَعَوْنا قادة الرعاية الملطِّفة في إقليم شرق المتوسط لاستخدام تلك الصيغة لوصف حالات النجاح في تنفيذ الرعاية الملطِّفة في بلدانهم والتحديات التي تُُجابهها.
UNASSIGNED: بالإضافة للعديد من التحديات والاحتياجات، يضم إقليم شرق المتوسط أمثلة على النجاح في وضع سياسات الرعاية الملطِّفة، وتوفير الخدمات المجتمعية، وتنفيذ الرعاية الملطِّفة للأطفال.
UNASSIGNED: إن خبرات رواد الرعاية الملطِّفة بالإقليم، الموثقة في هذه الورقة البحثية، يمكن أن تساعد في توجيه تطوير الرعاية التلطيفية الإقليمية في منطقة الشرق الأوسط ومناطق أخرى.
Modèles de soins palliatifs et innovations en la matière dans quatre pays de la Région de la Méditerranée orientale : étude de cas.
UNASSIGNED: Il existe un accord mondial sur le fait que les soins palliatifs devraient être universellement accessibles. Cependant, dans les pays à revenu faible et intermédiaire et les zones de conflit, la plupart des personnes n\' y ont pas accès. Dans la Région de la Méditerranée orientale, aucun pays n\'est parvenu à intégrer les soins palliatifs dans son système de soins de santé, et seuls quatre pays disposent d\'une offre de soins palliatifs qui sont en voie d\'intégration.
UNASSIGNED: Promouvoir et guider l\'amélioration des soins palliatifs dans la Région de la Méditerranée orientale, par le biais d\'études de cas montrant les succès et les défis de la mise en œuvre des soins palliatifs dans quatre pays de la Région.
UNASSIGNED: Nous avons mis au point un modèle de rédaction de cas structuré et succinct, et nous avons invité les responsables des soins palliatifs dans la Région de la Méditerranée orientale à s\'en servir pour décrire les succès et les défis de la mise en œuvre de ces soins dans leurs pays.
UNASSIGNED: Dans la Région de la Méditerranée orientale, outre les nombreux défis et besoins, il existe des exemples de réussite concernant l\'élaboration de politiques en matière de soins palliatifs, la mise en place de services communautaires et la mise en œuvre des soins palliatifs pédiatriques.
UNASSIGNED: Les expériences réalisées par les responsables régionaux des soins palliatifs, qui sont documentées dans des études de cas structurées succintes, permettent de guider la mise en place des soins palliatifs au niveau régional.

Clinically relevant information from electronic health records (EHRs) permits derivation of a rich collection of phenotypes. Unlike traditionally designed studies where scientific hypotheses are specified a priori before data collection, the true phenotype status of any given individual in EHR-based studies is not directly available. Structured and unstructured data elements need to be queried through preconstructed rules to identify case and control groups. A sufficient number of controls can usually be identified with high accuracy by making the selection criteria stringent. But more relaxed criteria are often necessary for more thorough identification of cases to ensure achievable statistical power. The resulting pool of candidate cases consists of genuine cases contaminated with noncase patients who do not satisfy the control definition. The presence of patients who are neither true cases nor controls among the identified cases is a unique challenge in EHR-based case-control studies. Ignoring case contamination would lead to biased estimation of odds ratio association parameters. We propose an estimating equation approach to bias correction, study its large sample property, and evaluate its performance through extensive simulation studies and an application to a pilot study of aortic stenosis in the Penn medicine EHR. Our method holds the promise of facilitating more efficient EHR studies by accommodating enlarged albeit contaminated case pools.

There is a need to understand how patients are managed in the real world to better understand disease burden and unmet need. Traditional approaches to gather these data include the use of electronic medical record (EMR) or claims databases; however, in many cases data access policies prevent rapid insight gathering. Social media may provide a potential source of real-world data to assess treatment patterns, but the limitations and biases of doing so have not yet been evaluated. Here, we assessed whether patient treatment patterns extracted from publicly available patient forums compare to results from more traditional EMR and claims databases. We observed that the 95% confidence intervals of proportions of treatments received at first, second, and third line for advanced/metastatic melanoma generated from unstructured social media data overlapped with 95% confidence intervals from proportions obtained from 1 or more traditional EMR/Claims databases. Social media may offer a valid data option to understand treatment patterns in the real world.

The electronic medical record (EMR) can reveal preferences of clinicians regarding imaging services. We sought to evaluate viewing habits for reports and images of musculoskeletal (MSK) studies by ordering clinicians. We hypothesized that MSK reports are important to clinical management, especially for advanced imaging modalities. We tracked the image and report access of all MSK studies ordered in September 2016 over 8 months using logs of the EMR (Epic Systems, Verona, WI), and by an independent analysis of the institutional PACS (Picture Archiving and Communication Systems) (Carestream Health, Rochester, NY). The time stamps were extracted for when images and reports were viewed. We categorized MSK studies by modality and provider department. We also compared the rates of viewing reports and images among different modalities and departments using the chi-square test. Of the 8143 viewed MSK studies, 7842 (96.3%) reports (with/without images) and 3916 (48.1%) imaging data (with/without reports) were viewed. Viewing reports alone occurred in 4227 (51.9%) studies. CT and MRI reports alone views occurred more often in comparison to radiographs ([482/706; 68.3%] for CT and [981/1713; 57.3%] for MRI vs. [2764/5724; 48.3%] for radiography, p < 0.001). Orthopedists ordered the highest number of MSK studies and viewed reports 99.2% (3216/3242) of the time, including a 54.6% (1770/3242) rate of viewing reports alone and a 44.6% (1446/3242) rate of viewing both reports and images. They viewed images without reports in 0.8% (27/3242) of cases. MSK reports were viewed significantly more frequently than the images across all modalities and all relevant specialties.

BACKGROUND: Iatrogenic perforation during therapeutic colonoscopy, reported in up to 1% of endoscopic mucosal resections (EMRs) and up to 14% of endoscopic submucosal dissections (ESDs), has conventionally been an indication for surgery.
OBJECTIVE: We present a case series of successful endoscopic management of iatrogenic colorectal perforation during EMR and ESD, demonstrating the feasibility and safety of the method.
METHODS: Retrospective analysis of a database of patients undergoing EMR and ESD for colorectal polyps in a tertiary referral centre in the United Kingdom.
RESULTS: Four cases of perforation were identified (two EMRs and two ESDs) in a series of 218 procedures (1.8%), all detected at the time of endoscopy and managed with endoscopic clips. Patients were observed in hospital and treated with antibiotics. Their median length of stay was 3 days (range 2-6 days), with no mortality or need for surgery.
CONCLUSIONS: Surgery is no longer the first choice in the management of iatrogenic perforations during EMR and ESD for colorectal polyps; in selected patients with small perforations and minimal extraluminal contamination, conservative management with application of endoscopic clips, antibiotics and close patient monitoring constitute a safe and effective treatment option, avoiding the morbidity of major surgery.