607. Improving Health Maintenance Among Patients with HIV by Implementing a SmartPhrase and a Care Gap in the EPIC Electronic Medical Record

Abstract Background Most deaths in HIV-infected patients receiving antiretroviral therapy are now related to conditions other than AIDS. HIV infection appears to increase the risk of many non-AIDS-related conditions, highlighting the importance of preventive care, however, recommended health maintenance items unique patients with HIV (PWH) are not always accomplished. We aimed to improve health maintenance by implementing a SmartPhrase and a Care Gap package in the EPIC Electronic Medical Record (EMR). Methods We developed a HIV health maintenance SmartPhrase in EPIC that included the last screening dates for syphilis, gonorrhea, chlamydia, hepatitis A, hepatitis B, hepatitis C, latent tuberculosis, hyperlipidemia, diabetes and human papilloma virus and the dates of receipt of hepatitis A vaccines, hepatitis B vaccines, pneumococcal conjugate vaccines, pneumococcal polysaccharide vaccines and influenza vaccines (Figure 1). Providers can select their plan for each health maintenance item based on these data and their plans are documented in the encounter notes. Providers were educated to use the SmartPhrase in each office visit. An HIV registry was built after choosing 509 HIV related medical conditions. The health maintenance topics were displayed in a “Care Gaps” summary using the data in the HIV registry (Figure 2). Completion rates for the health maintenance items were compared before and after implementation. The health maintenance package was implemented on 3/1/2020. Figure 1. SmartPhrase .IDNOTE description and note documentation Information relevant to health maintenance and providers' plan for each health maintenance are documented in the encounter notes. Figure 2. CareGaps© 2021 Epic Systems Corporation CD4 every 6 months is displayed as a part of the health maintenance in a “Care Gaps” summary using the data in the HIV registry, whether their HIV is well controlled or not. Results Of the 380 patients in the registry, 162 had office visits with the ID clinic from 1/1/20 to 6/5/20. Chart review of 100 patients who had office visits after implementation was performed and compared to the 62 patients prior to implementation (Table 1). The rates of hepatitis A vaccination (P= 0.001), hepatitis B vaccination (P= 0.05) and influenza vaccination (P=0.035) were increased significantly. Pneumonia vaccine administrations and anal pap smear performance compliance remained suboptimal. Providers reported that the time they spent searching for lab results and immunization records and documenting were shortened. The rates of hepatitis A vaccination (P= 0.001), hepatitis B vaccination (P= 0.05) and influenza vaccination (P=0.035) were increased significantly. Conclusion A health maintenance package consisting of a SmartPhrase and summary display in the EMR with provider education likely helps improve health maintenance in PWH. Disclosures All Authors: No reported disclosures

Exhibit 1. Level (%) of Agreement to "I was satisfied with the overall quality of the services provided" by Age Group (n = 5,559)

Conclusion.
Analysis of each survey question shows the 65+ patients are less satisfied than younger patients on the following: being informed of side effects, explanation of financial responsibilities, and the helpfulness of the billing staff. Even though the scores are high for both age groups, additional research needs to be conducted to determine why scores for the 65+ age group are lower, and changes needed for improvement. Knowing the level of OPAT patient satisfaction will benefit infectious disease physicians, providers, prescribers, payers, and regulators as they evaluate how to expand home-based services.
Disclosures. Background. Recent studies suggest that early post-discharge follow-up for patients receiving outpatient parenteral antimicrobial therapy (OPAT) reduces readmission rates. We report our experience implementing a telehealth-based clinic to facilitate early (1-2 week) follow-up for selected OPAT patients perceived to be at high risk for readmission.
Methods. We identified patients who met criteria for and completed a supplemental OPAT telehealth visit following the initial seven months after implementation of this clinic (11/1/20 -5/31/21). Clinical criteria triggering intake of patients for these visits included: endovascular or cardiac device-related infection; treatment with vancomycin, oxacillin/nafcillin, or aminoglycosides; ≥2 prior hospitalizations within past 1 year; treating Infectious Disease or OPAT team's subjective assessment of high readmission risk. Patients planned for < 14 days of OPAT therapy were excluded. Categorical variables were compared using a Chi-square test at the α=0.05 level of significance.
Results. A total of 49 patients completed a telehealth visit; mean time from discharge to telehealth visit was 12.1 days (SD +/-3.9). An intervention was made in 27% of these visits (13 of 49 patients), most commonly involving attempted mitigation of an adverse event or line-related complication (7 cases). The all-cause, 30-day readmission rate for this cohort was 6.1% (3 of 49 patients), while the rate for OPAT patients who did not receive an early telehealth visit during the same period was 22.7% (52 of 229 patients) which was statistically significant (p=0.008). This association of benefit was also found when comparing infection-related, 30-day readmission rates (0% vs 7.4%, p=0.049).
Conclusion. Implementation of OPAT telehealth encounters for high-risk patients resulted in a high rate of intervention to mitigate adverse events of OPAT therapy. Readmission occurred less than one-third as frequently in the telehealth group compared to patients with no early follow-up visit. Telehealth-based encounters appear comparable in effectiveness to those previously reported utilizing in-person visits, introducing efficiencies that may allow for broader implementation of this intervention.
Disclosures. Nicolas W. Cortes-Penfield, MD, Nothing to disclose Bryan Alexander, PharmD, Astellas Pharma (Advisor or Review Panel member) Background. Most deaths in HIV-infected patients receiving antiretroviral therapy are now related to conditions other than AIDS. HIV infection appears to increase the risk of many non-AIDS-related conditions, highlighting the importance of preventive care, however, recommended health maintenance items unique patients with HIV (PWH) are not always accomplished. We aimed to improve health maintenance by implementing a SmartPhrase and a Care Gap package in the EPIC Electronic Medical Record (EMR).

Improving Health Maintenance Among Patients with HIV by Implementing a SmartPhrase and a Care Gap in the EPIC Electronic Medical Record
Methods. We developed a HIV health maintenance SmartPhrase in EPIC that included the last screening dates for syphilis, gonorrhea, chlamydia, hepatitis A, hepatitis B, hepatitis C, latent tuberculosis, hyperlipidemia, diabetes and human papilloma virus and the dates of receipt of hepatitis A vaccines, hepatitis B vaccines, pneumococcal conjugate vaccines, pneumococcal polysaccharide vaccines and influenza vaccines (Figure 1). Providers can select their plan for each health maintenance item based on these data and their plans are documented in the encounter notes. Providers were educated to use the SmartPhrase in each office visit. An HIV registry was built after choosing 509 HIV related medical conditions. The health maintenance topics were displayed in a "Care Gaps" summary using the data in the HIV registry (Figure 2). Completion rates for the health maintenance items were compared before and after implementation. The health maintenance package was implemented on 3/1/2020. Figure 1. SmartPhrase .IDNOTE description and note documentation Information relevant to health maintenance and providers' plan for each health maintenance are documented in the encounter notes. Figure 2. CareGaps© 2021 Epic Systems Corporation CD4 every 6 months is displayed as a part of the health maintenance in a "Care Gaps" summary using the data in the HIV registry, whether their HIV is well controlled or not.
Results. Of the 380 patients in the registry, 162 had office visits with the ID clinic from 1/1/20 to 6/5/20. Chart review of 100 patients who had office visits after implementation was performed and compared to the 62 patients prior to implementation ( Table 1). The rates of hepatitis A vaccination (P= 0.001), hepatitis B vaccination (P= 0.05) and influenza vaccination (P=0.035) were increased significantly. Pneumonia vaccine administrations and anal pap smear performance compliance remained suboptimal. Providers reported that the time they spent searching for lab results and immunization records and documenting were shortened.
The rates of hepatitis A vaccination (P= 0.001), hepatitis B vaccination (P= 0.05) and influenza vaccination (P=0.035) were increased significantly.

Conclusion.
A health maintenance package consisting of a SmartPhrase and summary display in the EMR with provider education likely helps improve health maintenance in PWH.
Disclosures. All Authors: No reported disclosures

Session: P-27. Clinical Practice Issues
Background. Continuous infusion (CI) vancomycin has been reported to be associated with improved safety outcomes compared to intermittent infusion (II) in the outpatient parenteral antimicrobial therapy (OPAT) setting. Based on this our institution implemented a quality improvement intervention to discharge more patients on CI vancomycin aiming to improve vancomycin safety in our OPAT program.
Methods. This single-center, pre-/post-intervention, quasi-experimental study evaluated adult patients who received vancomycin for a minimum 7-day intended duration of therapy after discharge, were discharged to home health or a skilled nursing facility, and had a follow-up visit with an infectious diseases provider. Outcomes included discontinuation due to acute kidney injury (AKI) or due to any adverse drug event (ADE), time to AKI or ADE, and unplanned 30-day readmissions and were compared between the pre-intervention (11/25/2018 to 7/5/2020) and post-intervention (7/6/2020 to 3/31/2021) periods. Adverse events were defined as premature discontinuation of vancomycin with documentation of a suspected adverse event.
Results. Of the 445 patients included, 102 patients received CI vancomycin. Demographic characteristics were generally similar between time periods, although more patients discharged to home health were included during the post-intervention period. CI vancomycin use was higher after the intervention (42% vs 11%, P < 0.0001). Discontinuation due to AKI (7% vs 8%, P = 0.68) or any ADE (16% vs 18%, P = 0.65) occurred just as frequently post-implementation. Unplanned 30-day readmission was higher post-intervention (21% vs 12%, P = 0.02). When comparing patients receiving CI and II vancomycin, discontinuation rates due to AKI (10% with CI vs 7% with II, P = 0.35) and any ADE (17% with CI vs 17% with II, P = 0.85) were similar. Time to AKI (median 21 days with CI vs 16 days with II, P = 0.26) and any ADE (median 22 days vs 22 days, P = 0.55) were also similar. There was a trend toward a significantly higher unplanned 30-day readmission rate with use of CI compared to II (22% vs 14%, P = 0.07).
Control Charts These control charts show the variation over time of the proportion of patients A. utilizing CI vancomycin, B. experiencing any adverse drug reaction, C. experiencing acute kidney injury, and D. being readmitted within 30 days. Upper and lower control limits are depicted by red lines, and the mean is depicted by a green line.
Conclusion. We found no safety advantages when using CI instead of II vancomycin in the outpatient setting. The potentially higher readmission rate observed with CI vancomycin will be investigated further.