Study design and populations
Survey data and chart data were collected before (June 2017 – January 2019) and after (March 2019 – January 2020) our EMR intervention. Data was collected from the rheumatology and dermatology clinics of the University of Utah Medical Center in Salt Lake City, Utah, USA.
Chart data was taken from the EMR of outpatient clinic encounters. Through the University of Utah’s enterprise data warehouse, non-identified data was queried from all rheumatology and dermatology encounters which were documented during these two time periods and in which HCQ was prescribed as part of the visit. If a patient had more than one outpatient encounter that met these criteria (with rheumatology or dermatology) during the time period, then only the most recent encounter was used. Data queried included: the most recently recorded weight (even if this was not associated with the encounter in question), recorded gender, the diagnosis linked with the HCQ prescription in the EMR, and all available prescriptions details associated with the HCQ order. No patient identifying data was collected. If no weight was on record, or if other prescription details were missing that prevented us from being able to calculate the daily dose of HCQ, then the record was removed from further analysis. Queried data assimilation and organization was conducted (RO) for subsequent statistical analysis (RO, JP).
Survey data was also collected before and after our EMR intervention. Potential features of the pre-intervention and post-intervention surveys were explored (RO, DO, CH, JP), the surveys were then written (RO) and reviewed before use (RO, DO, CH, JP). No pilot testing or cognitive interviewing was conducted. Pre-intervention surveys were anonymous paper surveys for rheumatologists (distributed and collected by an administrative assistant not associated with the study). Due to lack of proximity, the same. anonymous surveys were instead e-mailed to dermatologists. Post-intervention surveys were anonymous e-mailed online surveys for both rheumatologists and dermatologists, due to ease of distribution and anonymity. Every member of our rheumatology and dermatology divisions (faculty, advanced practitioners, and fellows) were asked to participate in the surveys, both before and after our intervention. Participation was voluntary. The surveys consisted of multiple-choice or yes/no questions. Survey data analyzed included: self-reported awareness of guidelines, multiple choice questions regarding dosing recommendations of the guidelines, self-reported compliance with guidelines, and opinions regarding these guidelines (full surveys are available in the supplemental materials).
Formal institutional review board (IRB) approval at the University of Utah was obtained for medical record review and the enrollment of the providers for completion of anonymous surveys. As this was primarily a quality improvement project and was low risk, this study qualified for IRB exemption. (IRB 00132645). Consent cover letter was provided to providers for completion of anonymous surveys.
Our intervention was the implementation of an EMR tool. This tool was a box which would appear on the screen of the EMR in any outpatient encounter when a provider proceeded to order the medication HCQ. This box would prompt the provider, when choosing the dose signature, to “click” a 5 mg/kg/day dose button. This box also simultaneously highlighted a reference to the 2016 AAO guidelines supporting this recommendation. If no weight was on record in the chart, an error message resulted. Alternative options included to “click” 400 mg daily or to enter an alternative dosing schedule manually. If a weight was on record in the chart, and the prescribed value (regardless of the option used) exceeded 5 mg/kg/day, then the provider received a dose warning message. This tool was not a “hard stop”. Providers were not required to select the recommended weight-based dose and were not required to justify their reasons for prescribing a higher dose. The EMR tool did not record data as to which of these dosing options was chosen. The only recorded variable for analysis was the final daily dose.
Measurement and outcomes
We analyzed HCQ prescribing habits of the providers and their compliance with the 2016 AAO guidelines. We also collected the providers’ opinions and reasons for practice deviations from the guidelines in survey form. Finally, we evaluated whether introduction of the EMR tool correlated with any change in the rate of compliance and providers’ perspectives on the guidelines.
Demographic data and ABW-based HCQ dosing prescriptions were presented as frequencies and percentages. Comparisons of proportions before and after the intervention were calculated using Fisher’s exact tests. The p-value of < 0.05 was considered statistically significant.