David M. Sibell

Implementation of a Novel Electronic Health Record-Embedded Physician Orders for Life-Sustaining Treatment System

In April 2015, Oregon Health & Science University (OHSU) deployed a web-based, electronic medical record-embedded application created by third party vendor Vynca Inc. to allow real-time education, and completion of Physician Orders for Life Sustaining Treatment (POLST). Forms are automatically linked to the Epic Systems™ electronic health record (EHR) patient header and submitted to a state Registry, improving efficiency, accuracy, and rapid access to and retrieval of these important medical orders. POLST Forms, implemented in Oregon in 1992, are standardized portable medical orders used to document patient treatment goals for end-of-life care. In 2009, Oregon developed the first POLST-only statewide registry with a legislative mandate requiring POLST form signers to register the form unless the patient opts out. The Registry offers 24/7 emergency access to POLST Forms for Emergency Medical Services, Emergency Departments, and Acute Care Units. Because POLST is intended for those nearing end of life, immediate access to these forms at the time of an emergency is critical. Delays in registering a POLST Form may result in unwanted treatment if the paper form is not immediately available. An electronic POLST Form completion system (ePOLST) was implemented to support direct Registry submission. Other benefits of the system include single-sign-on, transmission of HL7 data for patient demographics and other relevant information, elimination of potential errors in form completion using internalized logic, built-in real-time video and text-based education materials for both patients and health care professionals, and mobile linkage for signature capture.

ACGME Sports, ACGME Pain, or Non-ACGME Sports and Spine: Which Is the Ideal Fellowship Training for PM&R Physicians Interested in Musculoskeletal Medicine?

R.J. is a third-year physical medicine and rehabilitation resident. She has a strong interest in general musculoskeletal medicine, including spine care and interventional procedures. She envisions a practice that is a mixture of acute and chronic musculoskeletal and spine injuries, with the ability to see all age groups, from young patients with acute traumatic injuries to patients with age-related degenerative changes. She plans on doing electromyograms for her own patients as well as interventional procedures in the lumbar spine and peripheral joints by using fluoroscopy and ultrasound. She wants to be a clinician educator at an academic physical medicine and rehabilitation program due to her love of teaching. She plans on going to a fellowship for additional training and possibly certification. Her coresidents have told her that she will only be able to perform fluoroscopic spine procedures after her fellowship if she completes an Accreditation Council for Graduate Medical Education (ACGME) pain medicine fellowship. She is concerned that there are ACGME requirements for a pain fellowship that she has no interest in, for example, cancer pain. She also does not think that she wants to be a “pain physician.” She likes the idea of an ACGME sports medicine fellowship, but her goals are general musculoskeletal and spine care and not necessarily sideline coverage. She also has been told that sports medicine board certification is essential for an academic job in a physical medicine and rehabilitation department. Several non-ACGME fellowships, some even at academic institutions, do fulfill her educational goals, but she is worried that she may not be able to get a job or even get credentialed to preform interventional procedures after engaging in such a fellowship. E. Kano Mayer, MD, will argue that a non-ACGME fellowship may better suit her educational desires. Joe Ihm, MD, and Joel Press, MD, will argue that she should do an ACGME sports medicine fellowship. David Sibell, MD, will argue she should consider an ACGME pain fellowship. Guest Discussants:

Failure to ventilate through a double-lumen tube due to carinal shift during lung volume reduction surgery

D ifficulties with ventilation during anesthetic procedures with endobronchial double-lumen tubes (DLTs) can usually be attributed to DLT malposition or malfunction. While these can readily be iorrected, other problems relating to anatomic variations are more difficult to solve. Most such anatomic variations are congenital, but we report a case of ventilatory difficulty with a properly positioned DLT during bilateral lung volume reduction surgery (“lung shaving”) (1). In this patient, the difficulty seemed to arise from an acquired abnormality as a result of progressive pulmonary disease.

Patient and Procedural Risk Factors for Cortisol Suppression Following Epidural Steroid Injections for Spinal Stenosis

Disclosures: Fheza Saleem: I Have No Relevant Financial Relationships To Disclose Objective: To demonstrate that patients with back pain have excessive use of narcotics vs. NSAIDS and higher level of other medication use compared to their age cohorts, indicating significant comorbidities. Design: Retrospective epidemiologic cohort study of claims data from data from The Marketscan commercial and Medicare claims databases. Search criteria: 1) Two claims in one year of back pain between 1/1/2009 7/31/2015; 2) Enrolled for 24 months after the 2nd back pain diagnosis. Patients were divided into cohorts 40-64 years old and 65-75 years old. Setting: Commercial Insurance Claims Database. Participants: Claims data from participating Insurance companies. Interventions: Not applicable. Main Outcome Measures: Medication use reported as percent of patients. Chi squared analyses for between group comparisons. Odds ratio (OR) and confidence Intervals (CI) reported as OR (CI). Results: In the 40-64 year-old group patients with back pain (BP+) (N1⁄4912,182), were compared to patients without back pain (BP-) (N1⁄44,518,202). Opiates: 28.4% in BP+ vs. 4.2% in BP-, 8.97(8.92-9.03); NSAIDS 18.1% BP+ vs. 3.6% BP-, 5.98 (5.94-6.02); anti-hyperlipidemics 18.2% BP+ vs. 12.2% BP-, 1.60 (1.59-1.61); antidepressants 18.9% BP+ vs. 7.6% BP-, 2.84 (2.82-2.86); beta-blockers 9.3% BP+ vs. 6.0% BP-, 1.61 (1.60-1.62); hypoglycemics 5.6% BP+ vs. 3.7% BP-, 1.55 (1.531.56). P .001 for all values. In the 65-75yr group patients with back pain (BP+) (N1⁄4164,738), were compared to patients without back pain (BP-) (N1⁄4744,560). Opiates: 30.5% in BP+ vs. 5.6% in BP-, 7.39 (7.277.50); NSAIDS 17.5% BP+ vs. 4.9% BP-, 4.10 (4.03-4.17); anti-hyperlipidemics 36.7% BP+ vs. 28.6% BP-, 1.44 (1.43-1.46); antidepressants 18.2% BP+ vs. 7.7% BP-, 2.67 (2.62-2.71); beta-blockers 21.6% BP+ vs. 16.8% BP-, 1.37 (1.35-1.38); hypoglycemics 10.5% BP+ vs. 8.0% BP-, 1.36 (1.34-1.39). P .001 for all values. Conclusions: In a large database looking at privately insured patients, we can see that narcotic use is higher that NSAID use for back pain, and evaluating other medication use indicates higher comorbidities in the BP+ group. In the older population the gap between comorbidities seems to narrow. Supported by an unrestricted grant from the Everest Foundation. Level of Evidence: Level IV