Yauheni Solad

Objective To address challenges in large-scale electronic health record (EHR) data exchange, we sought to develop, deploy, and test an open source, cloud-hosted app ‘listener’ that accesses standardized data across the SMART/HL7 Bulk FHIR Access application programming interface (API). Methods We advance a model for scalable, federated, data sharing and learning. Cumulus software is designed to address key technology and policy desiderata including local utility, control, and administrative simplicity as well as privacy preservation during robust data sharing, and AI for processing unstructured text. Results Cumulus relies on containerized, cloud-hosted software, installed within a healthcare organization’s security envelope. Cumulus accesses EHR data via the Bulk FHIR interface and streamlines automated processing and sharing. The modular design enables use of the latest AI and natural language processing tools and supports provider autonomy and administrative simplicity. In an initial test, Cumulus was deployed across five healthcare systems each partnered with public health. Cumulus output is patient counts which were aggregated into a table stratifying variables of interest to enable population health studies. All code is available open source. A policy stipulating that only aggregate data leave the institution greatly facilitated data sharing agreements. Discussion and Conclusion Cumulus addresses barriers to data sharing based on (1) federally required support for standard APIs (2), increasing use of cloud computing, and (3) advances in AI. There is potential for scalability to support learning across myriad network configurations and use cases.

Objective: To evaluate the real-world performance in delivering patient data on populations, of the SMART/HL7 Bulk FHIR Access API, required in Electronic Health Records (EHRs) under the 21st Century Cures Act Rule. Materials and Methods: We used an open-source Bulk FHIR Testing Suite at five healthcare sites from April to September 2023, including four hospitals using EHRs certified for interoperability, and one Health Information Exchange (HIE) using a custom, standards-compliant API build. We measured export speeds, data sizes, and completeness across six types of FHIR resources. Results: Among the certified platforms, Oracle Cerner led in speed, managing 5-16 million resources at over 8,000 resources/min. Three Epic sites exported a FHIR data subset, achieving 1-12 million resources at 1,555-2,500 resources/min. Notably, the HIE’s custom API outperformed, generating over 141 million resources at 12,000 resources/min. Discussion: The HIE’s custom API showcased superior performance, endorsing the effectiveness of SMART/HL7 Bulk FHIR in enabling large-scale data exchange while underlining the need for optimization in existing EHR platforms. Agility and scalability are essential for diverse health, research, and public health use cases. Conclusion: To fully realize the interoperability goals of the 21st Century Cures Act, addressing the performance limitations of Bulk FHIR API is critical. It would be beneficial to include performance metrics in both certification and reporting processes.

Background: Nearly 1 in 5 patients suffers from inadequate or poor bowel preparation in advance of a colonoscopy. Prior studies have shown that this leads to a decrease in adenoma detection rate, increased time spent in completing efficiency in endoscopy suite, as well as an overall increase in cost of care from 13-20%. With the shift to value-based care in the American healthcare system, there is an urgent need for solutions that can automate pre-procedure guidance and post-procedure follow up. Objective: As part of the American Gastroenterology Association digital transformation network, we sought to automate and improve pre-procedure navigation for colonoscopy using connected health technologies (specifically digital navigation). At Arizona Center for Digestive Health (AZCDH), we assessed the impact of digital navigation on bowel preparation quality, patient engagement, and patient satisfaction. We also sought to assess the reproducibility of outcomes seen at AZCDH at additional sites that have implemented digital navigation for endoscopic procedures as part of the American Gastroenterology Association network, including Yale New Haven Hospital (YNHH) and three Mount Sinai Hospital locations. Methods: At AZCDH, we compared two cohorts of patients (usual care versus digital navigation) scheduled for colonoscopy. The digital navigation cohort received usual care in addition to time based messages and education content pathways on smartphones and delivered through Rx.Health’s digital medicine platform. Bowel preparation quality was then assessed, as well as patient satisfaction with the digital navigation intervention. Patient engagement and satisfaction were then compared with initial data from other sites within the network. Results: Of the 217 patients prescribed the digital navigation program at AZCDH, 93 completed the procedure to date and had bowel preparation results documented in the electronic endoscopic record system. After implementing the digital navigation program the rate of aborted procedures decreased from 2.2% at baseline to 1.07%. In a follow up survey, 93% of respondents “strongly agreed” or “agreed” that the digital navigation program was helpful in preparing for their colonoscopy. At other locations to date, 433 patients have been prescribed the pathway at YNHH along with 213 patients at Mount Sinai locations. One hundred percent and 94% of respondents “strongly agreed” or “agreed” that the digital navigation program was helpful in preparing for their procedure at YNHH and Mount Sinai locations, respectively. Conclusions: Our single-site study at AZCDH paved the way to implementing digital navigation pathways at YNHH and Mount Sinai endoscopy locations by demonstrating that colonoscopy instructions are well received by patients, can reduce the rate of aborted procedures and can result in higher patient satisfaction as well as a higher quality of bowel preparation. Further, patient engagement rates and satisfaction with the program was consistent at all sites across the US where the digital navigation program has been implemented. In the future, we plan to report on patient outcomes (including reduction in no shows, poor bowel preparation) to allow benchmarking on a national scale.

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Emergency Departments (EDs) frequently care for individuals with Opioid Use Disorder (OUD). Buprenorphine (BUP) is an effective treatment option for patients with OUD that can safely be initiated in the ED. At present, BUP is rarely initiated as a part of routine ED care. Clinical decision support (CDS) could accelerate adoption of ED-initiated BUP into routine emergency care. Objective: To design and formatively evaluate a user-centered decision support tool for ED initiation of buprenorphine for patients with OUD. Methods: User-centered design with iterative prototype development was used. Initial observations and interviews identified workflows and information needs. The design team and key stakeholders reviewed prototype designs to ensure accuracy. Five prototypes were evaluated and iteratively refined informed by feedback from 26 attending and resident physicians until thematic saturation was reached. Results: Early feedback identified concerns with the initial CDS design: an alert with several screens. The timing of the alert led to quick dismissal without using the tool. User feedback on subsequent iterations informed the development of a flexible tool to support clinicians with varied levels experience with the intervention by providing both one-click options for direct activation of care pathways as well as user-activated support for critical decision points. The final design resolved challenging navigation issues through targeted placement, color, and design of the decision support modules and care pathways. In final testing, users expressed that the tool could be easily learned without training and was reasonable for use during routine emergency care. Conclusions: A user-centered design process helped designers to better understand users’ needs for a web-based clinical decision tool to support ED initiation of buprenorphine for OUD. The process identified varying needs across user experience and familiarity with the protocol, leading to a flexible design supporting both direct care pathways and user-initiated decision support. Clinical Trial: N/A for design,

BACKGROUND Emergency departments (EDs) frequently care for individuals with opioid use disorder (OUD). Buprenorphine (BUP) is an effective treatment option for patients with OUD that can safely be initiated in the ED. At present, BUP is rarely initiated as a part of routine ED care. Clinical decision support (CDS) could accelerate adoption of ED-initiated BUP into routine emergency care. OBJECTIVE This study aimed to design and formatively evaluate a user-centered decision support tool for ED initiation of BUP for patients with OUD. METHODS User-centered design with iterative prototype development was used. Initial observations and interviews identified workflows and information needs. The design team and key stakeholders reviewed prototype designs to ensure accuracy. A total of 5 prototypes were evaluated and iteratively refined based on input from 26 attending and resident physicians. RESULTS Early feedback identified concerns with the initial CDS design: an alert with several screens. The timing of the alert led to quick dismissal without using the tool. User feedback on subsequent iterations informed the development of a flexible tool to support clinicians with varied levels of experience with the intervention by providing both one-click options for direct activation of care pathways and user-activated support for critical decision points. The final design resolved challenging navigation issues through targeted placement, color, and design of the decision support modules and care pathways. In final testing, users expressed that the tool could be easily learned without training and was reasonable for use during routine emergency care. CONCLUSIONS A user-centered design process helped designers to better understand users’ needs for a Web-based clinical decision tool to support ED initiation of BUP for OUD. The process identified varying needs across user experience and familiarity with the protocol, leading to a flexible design supporting both direct care pathways and user-initiated decision support.