Lindsay Stevens

All Publications

• Centering Digital Health Equity During Technology Innovation: Protocol for a Comprehensive Scoping Review of Evidence-Based Tools and Approaches. JMIR research protocols Burns, K., Bloom, S., Gilbert, C., Merner, B., Kalla, M., Sheri, S., Villanueva, C., Matenga Ikihele, A., Nazer, L., Sarmiento, R. F., Stevens, L., Blow, N., Chapman, W. 2024; 13: e53855

  Abstract

  In the rush to develop health technologies for the COVID-19 pandemic, the unintended consequence of digital health inequity or the inability of priority communities to access, use, and receive equal benefits from digital health technologies was not well examined.This scoping review will examine tools and approaches that can be used during digital technology innovation to improve equitable inclusion of priority communities in the development of digital health technologies. The results from this study will provide actionable insights for professionals in health care, health informatics, digital health, and technology development to proactively center equity during innovation.Based on the Arksey and O'Malley framework, this scoping review will consider priority communities' equitable involvement in digital technology innovation. Bibliographic databases in health, medicine, computing, and information sciences will be searched. Retrieved citations will be double screened against the inclusion and exclusion criteria using Covidence (Veritas Health Innovation). Data will be charted using a tailored extraction tool and mapped to a digital health innovation pathway defined by the Centre for eHealth Research roadmap for eHealth technologies. An accompanying narrative synthesis will describe the outcomes in relation to the review's objectives.This scoping review is currently in progress. The search of databases and other sources returned a total of 4868 records. After the initial screening of titles and abstracts, 426 studies are undergoing dual full-text review. We are aiming to complete the full-text review stage by May 30, 2024, data extraction in October 2024, and subsequent synthesis in December 2024. Funding was received on October 1, 2023, from the Centre for Health Equity Incubator Grant Scheme, University of Melbourne, Australia.This paper will identify and recommend a series of validated tools and approaches that can be used by health care stakeholders and IT developers to produce equitable digital health technology across the Centre for eHealth Research roadmap. Identified evidence gaps, possible implications, and further research will be discussed.DERR1-10.2196/53855.

  View details for DOI 10.2196/53855

  View details for PubMedID 38838333

• MEASURING ASSOCIATIONS BETWEEN ELECTRONIC HEALTH RECORD USE AND INPATIENT PEDIATRIC PROVIDER BURNOUT Stevens, L., Su, F., Pageler, N., Tawfik, D., Sinha, A. LIPPINCOTT WILLIAMS & WILKINS. 2023: 40

  View details for Web of Science ID 000921450900081

• Clinical Informatics Through the Years Harper, M., Stevens, L., Lourie, E., Chartash, D., Krams, L., Suresh, S. Pediatrics. https://publications.aap.org/pediatrics/resources/24688/commentary-from-the-council-on-clinical. 2023 ; AAP Section/Committee/Council Retrospectives
• Medical Student and Trainee Notes in the Electronic Health Record Era. Chest Stevens, L. A., Pageler, N. M., Longhurst, C. A. 2022; 162 (6): 1238-1240

  View details for DOI 10.1016/j.chest.2022.08.2208

  View details for PubMedID 36494125

• Pediatric Subspecialty Adoption of Telemedicine Amidst the COVID-19 Pandemic: An Early Descriptive Analysis. Frontiers in pediatrics Xie, J., Prahalad, P., Lee, T. C., Stevens, L. A., Meister, K. D. 2021; 9: 648631

  Abstract

  Telemedicine has rapidly expanded in many aspects of pediatric care as a result of the COVID-19 pandemic. However, little is known about what factors may make pediatric subspeciality care more apt to long-term adoption of telemedicine. To better delineate the potential patient, provider, and subspecialty factors which may influence subspecialty adoption of telemedicine, we reviewed our institutional experience. The top 36 pediatric subspecialties at Stanford Children's Health were classified into high telemedicine adopters, low telemedicine adopters, and telemedicine reverters. Distance from the patient's home, primary language, insurance type, institutional factors such as wait times, and subspecialty-specific clinical differences correlated with differing patterns of telemedicine adoption. With greater awareness of these factors, institutions and providers can better guide patients in determining which care may be best suited for telemedicine and develop sustainable long-term telemedicine programming.

  View details for DOI 10.3389/fped.2021.648631

  View details for PubMedID 33928058

• Measuring Electronic Health Record Use in the Pediatric ICU Using Audit-Logs and Screen Recordings. Applied clinical informatics Sinha, A., Stevens, L. A., Su, F., Pageler, N. M., Tawfik, D. S. 2021; 12 (4): 737-744

  Abstract

   Time spent in the electronic health record (EHR) has been identified as an important unit of measure for health care provider clinical activity. The lack of validation of audit-log based inpatient EHR time may have resulted in underuse of this data in studies focusing on inpatient patient outcomes, provider efficiency, provider satisfaction, etc. This has also led to a dearth of clinically relevant EHR usage metrics consistent with inpatient provider clinical activity. The aim of our study was to validate audit-log based EHR times using observed EHR-times extracted from screen recordings of EHR usage in the inpatient setting. This study was conducted in a 36-bed pediatric intensive care unit (PICU) at Lucile Packard Children's Hospital Stanford between June 11 and July 14, 2020. Attending physicians, fellow physicians, hospitalists, and advanced practice providers with ≥0.5 full-time equivalent (FTE) for the prior four consecutive weeks and at least one EHR session recording were included in the study. Citrix session recording player was used to retrospectively review EHR session recordings that were captured as the provider interacted with the EHR. EHR use patterns varied by provider type. Audit-log based total EHR time correlated strongly with both observed total EHR time (r = 0.98, p < 0.001) and observed active EHR time (r = 0.95, p < 0.001). Each minute of audit-log based total EHR time corresponded to 0.95 (0.87-1.02) minutes of observed total EHR time and 0.75 (0.67-0.83) minutes of observed active EHR time. Results were similar when stratified by provider role. Our study found inpatient audit-log based EHR time to correlate strongly with observed EHR time among pediatric critical care providers. These findings support the use of audit-log based EHR-time as a surrogate measure for inpatient provider EHR use, providing an opportunity for researchers and other stakeholders to leverage EHR audit-log data in measuring clinical activity and tracking outcomes of workflow improvement efforts longitudinally and across provider groups.

  View details for DOI 10.1055/s-0041-1733851

  View details for PubMedID 34380167

• Improved Medical Student Engagement with EHR Documentation following the 2018 Centers for Medicare and Medicaid Billing Changes. Applied clinical informatics Stevens, L. A., Pageler, N. M., Hahn, J. S. 2021; 12 (3): 582-588

  Abstract

   Medical student note writing is an important part of the training process but has suffered in the electronic health record (EHR) era as a result of student notes being excluded from the billable encounter. The 2018 CMS billing changes allow for medical student notes to be used for billable services provided that physical presence requirements are met, and attending physicians satisfy performance requirements and verify documentation. This has the potential to improve medical student engagement and decrease physician documentation burden. Our institution implemented medical student notes as part of the billable encounter in August 2018 with support of our compliance department. Note characteristics including number, type, length, and time in note were analyzed before and after implementation. Rotating medical students were surveyed regarding their experience following implementation. There was a statistically significant increase in the number of student-authored notes following implementation. Attending physicians' interactions with student notes greatly increased following the change (4% of student notes reviewed vs. 84% of student notes). Surveyed students reported that having their notes as part of the billable record made their notes more meaningful and enhanced their learning. The majority of surveyed students also agreed that they received more feedback following the change. Medical students are interested in writing notes for education and feedback. Inclusion of their notes as part of the billable record can facilitate their learning and increase their participation in the note writing process.

  View details for DOI 10.1055/s-0041-1731342

  View details for PubMedID 34233368

• PEDIATRIC ICU ELECTRONIC HEALTH RECORD USAGE AS MEASURED BY AUDIT LOGS AND SCREEN RECORDINGS Sinha, A., Stevens, L., Su, F., Pageler, N., Tawfik, D. LIPPINCOTT WILLIAMS & WILKINS. 2021: 156

  View details for Web of Science ID 000672597100301

• Measuring success: perspectives from three optimization programs on assessing impact in the age of burnout. JAMIA open Lourie, E. M., Stevens, L. A., Webber, E. C. 2020; 3 (4): 492–95

  Abstract

  Electronic health record (EHR) optimization has been identified as a best practice to reduce burnout and improve user satisfaction; however, measuring success can be challenging. The goal of this manuscript is to describe the limitations of measuring optimizations and opportunities to combine assessments for a more comprehensive evaluation of optimization outcomes. The authors review lessons from 3 U.S. healthcare institutions that presented their experiences and recommendations at the American Medical Informatics Association 2020 Clinical Informatics conference, describing uses and limitations of vendor time-based reports and surveys utilized in optimization programs. Compiling optimization outcomes supports a multi-faceted approach that can produce assessments even as time-based reports and technology change. The authors recommend that objective measures of optimization must be combined with provider and clinician-defined value to provide long term improvements in user satisfaction and reduce EHR-related burnout.

  View details for DOI 10.1093/jamiaopen/ooaa056

  View details for PubMedID 33655200

• Electronic health record (EHR) training program identifies a new tool to quantify the EHR time burden and improves providers' perceived control over their workload in the EHR. JAMIA open DiAngi, Y. T., Stevens, L. A., Halpern-Felsher, B. n., Pageler, N. M., Lee, T. C. 2019; 2 (2): 222–30

  Abstract

  To understand if providers who had additional electronic health record (EHR) training improved their satisfaction, decreased personal EHR-use time, and decreased turnaround time on tasks.This pre-post study with no controls evaluated the impact of a supplemental EHR training program on a group of academic and community practice clinicians that previously had go-live group EHR training and 20 months experience using this EHR on self-reported data, calculated EHR time, and vendor-reported metrics.Providers self-reported significant improvements in their knowledge of efficiency tools in the EHR after training and doubled (significant) their preference list entries (mean pre = 38.1 [65.88], post = 63.5 [90.47], P < .01). Of the 7 EHR satisfaction variables, only 1 self-reported variable significantly improved after training: Control over my workload in the EHR (mean pre = 2.7 [0.96], post = 3.0 [1.04], P < .01). There was no significant decrease in their calculated EHR usage outside of clinic (mean pre = 0.39 [0.77] to post = 0.37 [0.48], P = .73). No significant difference was seen in turnaround time for patient calls (mean pre = 2.3 [2.06] days, post = 1.9 [1.76] days, P = .08) and results (mean before = 4.0 [2.79] days, after = 3.2 [2.33] days, P = .03).Multiple sources of data provide a holistic view of the provider experience in the EHR. This study suggests that individualized EHR training can improve the knowledge of EHR tools and satisfaction with their perceived control of EHR workload, however this did not translate into less Clinician Logged-In Outside Clinic (CLOC) time, a calculated metric, nor quicker turnaround on in box tasks. CLOC time emerged as a potential less-costly surrogate metric for provider satisfaction in EHR work than surveying clinicians. Further study is required to understand the cost-benefit of various interventions to decrease CLOC time.This supplemental EHR training session, 20 months post go-live, where most participants elected to receive 2 or fewer sessions did significantly improve provider satisfaction with perceived control over their workload in the EHR, but it was not effective in decreasing EHR-use time outside of clinic. CLOC time, a calculated metric, could be a practical trackable surrogate for provider satisfaction (inverse correlation) with after-hours time spent in the EHR. Further study into interventions that decrease CLOC time and improve turnaround time to respond to inbox tasks are suggested next steps.

  View details for DOI 10.1093/jamiaopen/ooz003

  View details for PubMedID 31984357

  View details for PubMedCentralID PMC6952029

• The Electronic Health Record The Art and Science of Physician Wellbeing: A Handbook for Physicians and Trainees. Sharp, C., Stevens, L. edited by Trockel, M., Roberts, L. Springer International Publishing. 2019; 1st Ed.: 87–102

  View details for DOI 10.1007/978-3-319-42135-3

• Designing An Individualized EHR Learning Plan For Providers. Applied clinical informatics Stevens, L. A., DiAngi, Y. T., Schremp, J. D., Martorana, M. J., Miller, R. E., Lee, T. C., Pageler, N. M. 2017; 8 (3): 924-935

  Abstract

  Electronic Health Records (EHRs) have been quickly implemented for meaningful use incentives; however these implementations have been associated with provider dissatisfaction and burnout. There are no previously reported instances of a comprehensive EHR educational program designed to engage providers and assist in improving efficiency and understanding of the EHR. Utilizing adult learning theory as a framework, Stanford Children's Health designed a tailored provider efficiency program with various inputs from: (1) provider specific EHR data; (2) provider survey data; and (3) structured observation sessions. This case report outlines the design of this individualized training program including team structure, resource requirements, and early provider response.Stevens LA, DiAngi YT, Schremp JD, Martorana MJ, Miller RE, Lee TC, Pageler NM. Designing An Individualized EHR Learning Plan. Appl Clin Inform 2017; 8:924-935 https://doi.org/10.4338/040054.

  View details for DOI 10.4338/ACI-2017-04-0054

  View details for PubMedID 30027541

• Successful Physician Training Program for Large Scale EMR Implementation. Applied clinical informatics Pantaleoni, J. L., Stevens, L. A., Mailes, E. S., Goad, B. A., Longhurst, C. A. 2015; 6 (1): 80-95

  Abstract

  End-user training is an essential element of electronic medical record (EMR) implementation and frequently suffers from minimal institutional investment. In addition, discussion of successful EMR training programs for physicians is limited in the literature. The authors describe a successful physician-training program at Stanford Children's Health as part of a large scale EMR implementation. Evaluations of classroom training, obtained at the conclusion of each class, revealed high physician satisfaction with the program. Free-text comments from learners focused on duration and timing of training, the learning environment, quality of the instructors, and specificity of training to their role or department. Based upon participant feedback and institutional experience, best practice recommendations, including physician engagement, curricular design, and assessment of proficiency and recognition, are suggested for future provider EMR training programs. The authors strongly recommend the creation of coursework to group providers by common workflow.

  View details for DOI 10.4338/ACI-2014-09-CR-0076

  View details for PubMedID 25848415

  View details for PubMedCentralID PMC4377562

• The Value of Clinical Teachers for EMR Implementations and Conversions. Applied clinical informatics Stevens, L. A., Pantaleoni, J. L., Longhurst, C. A. 2015; 6 (1): 75-79

  Abstract

  Effective physician training is an essential aspect of EMR implementation. However, it can be challenging to find instructors who can present the material in a clinically relevant manner. The authors describe a unique physician-training program, utilizing medical students as course instructors. This approach resulted in high learner satisfaction rates and provided significant cost-savings compared to alternative options.

  View details for DOI 10.4338/ACI-2014-09-IE-0075

  View details for PubMedID 25848414

  View details for PubMedCentralID PMC4377561

• Immunization registries in the EMR Era. Online journal of public health informatics Stevens, L. A., Palma, J. P., Pandher, K. K., Longhurst, C. A. 2013; 5 (2): 211-?

  Abstract

  The CDC established a national objective to create population-based tracking of immunizations through regional and statewide registries nearly 2 decades ago, and these registries have increased coverage rates and reduced duplicate immunizations. With increased adoption of commercial electronic medical records (EMR), some institutions have used unidirectional links to send immunization data to designated registries. However, access to these registries within a vendor EMR has not been previously reported.To develop a visually integrated interface between an EMR and a statewide immunization registry at a previously non-reporting hospital, and to assess subsequent changes in provider use and satisfaction.A group of healthcare providers were surveyed before and after implementation of the new interface. The surveys addressed access of the California Immunization Registry (CAIR), and satisfaction with the availability of immunization information. Information Technology (IT) teams developed a "smart-link" within the electronic patient chart that provides a single-click interface for visual integration of data within the CAIR database.Use of the tool has increased in the months since its initiation, and over 20,000 new immunizations have been exported successfully to CAIR since the hospital began sharing data with the registry. Survey data suggest that providers find this tool improves workflow and overall satisfaction with availability of immunization data. (p=0.009).Visual integration of external registries into a vendor EMR system is feasible and improves provider satisfaction and registry reporting.

  View details for DOI 10.5210/ojphi.v5i2.4696

  View details for PubMedID 23923096

• Clinical Report A Male With Down Syndrome, Fragile X Syndrome, and Autism JOURNAL OF DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS Stevens, L., Tartaglia, N., Hagerman, R., Riley, K. 2010; 31 (4): 333-337

  Abstract

  A case of a 14-year-old boy with both fragile X syndrome and Down syndrome is described. This is the third reported case of a patient with fragile X syndrome plus Down syndrome and the first reported case in a male. Facial features are generally consistent with Down syndrome; however, a prominent forehead and jaw and maccroorchidism were consistent with fragile X syndrome. Joint laxity is also present, which is consistent with both disorders. Cognitive impairment is more significant than in his siblings with fragile X syndrome, and he meets criteria for autistic disorder. Ongoing behavioral dysregulation has been significant, leading to disruption of home and school environments despite many attempted psychopharmacologic and behavioral strategies and a supportive family. Identification and treatment of underlying medical problems (esophagitis) led to improvements in sleep and behavior. We emphasize discussion of challenges in his behavioral management and present a collaborative approach to behavioral management.

  View details for DOI 10.1097/DBP.0b013e3181d5aa56

  View details for Web of Science ID 000277769600010

  View details for PubMedID 20453578