- Adolescent Medicine
Clinical Associate Professor, Pediatrics - Adolescent Medicine
Boards, Advisory Committees, Professional Organizations
Electronic Health Record Committee Member, Society for Adolescent Health and Medicine (2017 - 2020)
Member, Academic Pediatric Association (2014 - Present)
Member, American Academy of Pediatrics (2012 - Present)
Member, Society for Adolescent Health and Medicine (2015 - Present)
Board Certification: American Board of Pediatrics, Adolescent Medicine (2020)
Residency: Stanford Health Care at Lucile Packard Children's Hospital (2015) CA
Fellowship: Stanford University Adolescent Medicine Fellowship (2018) CA
Board Certification: American Board of Pediatrics, Pediatrics (2015)
Medical Education: University of California at San Francisco School of Medicine (2012) CA
MD, University of California, San Francisco (2012)
Residency, Stanford University Medical Center, Pediatrics (2015)
A Natural Language Processing Model to Identify Confidential Content in Adolescent Clinical Notes.
Applied clinical informatics
BACKGROUND: The 21st Century Cures Act mandates the immediate, electronic release of health information to patients. However, in the case of adolescents, special consideration is required to ensure that confidentiality is maintained. The detection of confidential content in clinical notes may support operational efforts to preserve adolescent confidentiality while implementing information sharing.OBJECTIVE: Determine if a natural language processing (NLP) algorithm can identify confidential content in adolescent clinical progress notes.METHODS: 1,200 outpatient adolescent progress notes written between 2016 and 2019 were manually annotated to identify confidential content. Labeled sentences from this corpus were featurized and used to train a two-part logistic regression model, which provides both sentence-level and note-level probability estimates that a given text contains confidential content. This model was prospectively validated on a set of 240 progress notes written in May 2022. It was subsequently deployed in a pilot intervention to augment an ongoing operational effort to identify confidential content in progress notes. Note-level probability estimates were used to triage notes for review and sentence-level probability estimates were used to highlight high-risk portions of those notes to aid the manual reviewer.RESULTS: The prevalence of notes containing confidential content was 21% (255/1200) and 22% (53/240) in the train/test and validation cohorts. The ensemble logistic regression model achieved an AUROC of 90% and 88% in the test and validation cohorts. Its use in a pilot intervention identified outlier documentation practices and demonstrated efficiency gains over completely manual note review.DISCUSSION: An NLP algorithm can identify confidential content in progress notes with high accuracy. Its human-in-the-loop deployment in clinical operations augmented an ongoing operational effort to identify confidential content in adolescent progress notes. These findings suggest NLP may be used to support efforts to preserve adolescent confidentiality in the wake of the information blocking mandate.
View details for DOI 10.1055/a-2051-9764
View details for PubMedID 36898410
EATING DISORDER CARE VIA TELEHEALTH: TELEHEALTH ACCESS AND QUALITY OF CARE AMONG YOUNG ADULTS AND ADOLESCENTS, 2018-2022
ELSEVIER SCIENCE INC. 2023: S55
View details for Web of Science ID 000995238000095
The Prevalence of Confidential Content in Adolescent Progress Notes Prior to the 21st Century Cures Act Information Blocking Mandate.
Applied clinical informatics
2023; 14 (2): 337-344
The 21st Century Cures Act information blocking final rule mandated the immediate and electronic release of health care data in 2020. There is anecdotal concern that a significant amount of information is documented in notes that would breach adolescent confidentiality if released electronically to a guardian.The purpose of this study was to quantify the prevalence of confidential information, based on California laws, within progress notes for adolescent patients that would be released electronically and assess differences in prevalence across patient demographics.This is a single-center retrospective chart review of outpatient progress notes written between January 1, 2016, and December 31, 2019, at a large suburban academic pediatric network. Notes were labeled into one of three confidential domains by five expert reviewers trained on a rubric defining confidential information for adolescents derived from California state law. Participants included a random sampling of eligible patients aged 12 to 17 years old at the time of note creation. Secondary analysis included prevalence of confidentiality across age, gender, language spoken, and patient race.Of 1,200 manually reviewed notes, 255 notes (21.3%) (95% confidence interval: 19-24%) contained confidential information. There was a similar distribution among gender and age and a majority of English speaking (83.9%) and white or Caucasian patients (41.2%) in the cohort. Confidential information was more likely to be found in notes for females (p < 0.05) as well as for English-speaking patients (p < 0.05). Older patients had a higher probability of notes containing confidential information (p < 0.05).This study demonstrates that there is a significant risk to breach adolescent confidentiality if historical progress notes are released electronically to proxies without further review or redaction. With increased sharing of health care data, there is a need to protect the privacy of the adolescents and prevent potential breaches of confidentiality.
View details for DOI 10.1055/s-0043-1767682
View details for PubMedID 37137339
View details for PubMedCentralID PMC10156443
MANAGING ADOLESCENT CONFIDENTIALITY IN THE ELECTRONIC HEALTH RECORD POST IMPLEMENTATION OF THE 21ST CENTURY CURES ACT FINAL RULE: A SURVEY OF PROVIDERS
ELSEVIER SCIENCE INC. 2023: S86
View details for Web of Science ID 000995238000152
Dobbs v. Jackson Decision: It's Time to Get Uncomfortable.
The recently announced decision of the Supreme Court in the Dobbs v. Jackson case has left health care providers, researchers, and administrators struggling to defend reproductive health care against legal restrictions. Although some hospital-based providers may not consider reproductive health care as part of their "wheelhouse," anyone who cares for adolescents and young adults must see this as a call to action. Reproductive health screening is often missed in the primary care setting1 which has led to recommendations to provide this care wherever adolescents and young adults present for care.2 As adolescents are under the legal age of majority and typically have less experience, education, and resources to help them access reproductive health care when needed, these new abortion laws will create disproportionate burdens on the adolescent population. For low-income youth and adolescent and young adults of color, this will likely worsen the disparities that already exist with regard to access to reproductive health care.3 Adolescents have the highest rates of unintended pregnancy4 and these pregnancies are more likely to end in abortion than adult pregnancies.5,6 Adolescents younger than age 20 make up 12% of individuals who have abortions in the US; minors who are 17 years or younger account for about 4% of all abortions in the US.7.
View details for DOI 10.1542/hpeds.2022-006829
View details for PubMedID 35799327
Implementation of an Inpatient Reproductive Health Screening Consult Service.
OBJECTIVES: Reproductive health is an important issue in the care of adolescents and young adults (AYA). Unfortunately, many AYAs, particularly those with chronic medical conditions, may not regularly access primary care to address these issues. This study evaluates the impact of an inpatient reproductive health consult service on reproductive health care.METHODS: A reproductive health-focused screening consult service was initiated in June 2017 at an academic teaching hospital. Patients aged 15 to 26 admitted to pediatric ward teams were eligible for screening. A retrospective chart review was conducted from December 2016 to June 2019 to determine the effect of the consult service on the primary outcome, documentation of a psychosocial assessment, and reproductive health concerns.RESULTS: Nine hundred twenty-nine encounters were analyzed (345 preintervention and 584 during intervention), representing 675 patients. The proportion of encounters with a documented psychosocial assessment increased from 14.8% to 41.3% during the intervention (P < .001); a reproductive health screening consult was responsible for 37.3% (109 of 292) of the documented assessments. There were high self-reported rates of sexual activity (38%), substance use (47%), and mood concerns (48%) among hospitalized AYA; all behaviors were documented at statistically significant increased frequencies (P < .001) during the intervention compared with preintervention.CONCLUSIONS: Initiation of an inpatient reproductive health screening consult service led to increased documentation of psychosocial assessments, including increased documentation of sexual health history and other risk factors. With improved screening of reproductive and psychosocial needs, targeted interventions can meet underrecognized needs among hospitalized AYA.
View details for DOI 10.1542/hpeds.2021-006178
View details for PubMedID 35165737
Low-Energy Availability and the Electronic Preparticipation Examination in College Athletes: Is There a Better Way to Screen?
Current sports medicine reports
2021; 20 (9): 489-493
ABSTRACT: The electronic preparticipation physical examination (ePPE) is commonly used to identify health conditions that would affect participation in sports for athletes, including disordered eating and/or low energy availability (EA). A secondary analysis was performed using a cohort study of female college athletes attending a Division 1 university between 2008 and 2014. Descriptive statistics and logistic regression analyses were used to explore the association between responses to questions on the ePPE related to eating behaviors and Female Athlete Triad (Triad). Risk categories (low, moderate, or high) were assigned to 239 athletes participating in 16 sports. The majority of responses on the ePPE did not identify athletes associated with moderate-/high-risk categories. Our findings suggest that ePPE may not sufficiently identify athletes at elevated risk for health concerns of the Triad. Our findings suggest that future ePPE may consider validated screening tools for disordered eating to help identify athletes at risk of low EA.
View details for DOI 10.1249/JSR.0000000000000880
View details for PubMedID 34524193
Improving Inpatient Consult Communication Through a Standardized Tool.
OBJECTIVES: To increase the number of essential consult elements (ECEs) included in initial inpatient consultation requests between pediatric residents and fellows through implementation of a novel consult communication tool.METHODS: Literature review and previous needs assessment of pediatric residents and fellows were used to identify 4 specific ECEs. From February to June 2018, fellows audited verbal consult requests at a medium-sized, quaternary care children's hospital to determine the baseline percentage of ECE components within consults. A novel consult communication tool containing all ECEs was then developed by using a modified situation-background-assessment-recommendation (SBAR) format. The SBAR tool was implemented over 3 plan-do-study-act cycles. Adherence to SBAR, inclusion of ECEs, and consult question clarity were tracked via audits of consult requests. A pre- and postintervention survey of residents and fellows was used to examine perceived miscommunication and patient care errors and overall satisfaction.RESULTS: The median percentage of consults containing ≥3 ECEs increased from 50% preintervention to 100% postintervention with consult question clarity increasing from 52% to 92% (P < .001). Overall perception of consult miscommunication frequency decreased (52% vs 18%; P < .01), although there was no significant change in resident- or fellow-reported patient errors. SBAR maintained residents' already high consult satisfaction (96% vs 92%; P = .39) and increased fellows' consult satisfaction (51% vs 91%; P < .001).CONCLUSIONS: Implementation of a standardized consult communication tool resulted in increased inclusion of ECEs. Use of the tool led to greater consult question clarity, decreased perceived miscommunication, and improved overall consult satisfaction.
View details for DOI 10.1542/peds.2020-0681
View details for PubMedID 33858984
- NASPAG/SAHM Statement: The 21st Century Cures Act and Adolescent Confidentiality. Journal of pediatric and adolescent gynecology 2021; 34 (1): 3–5
- NASPAG/SAHM Statement: The 21st Century Cures Act and Adolescent Confidentiality. The Journal of adolescent health : official publication of the Society for Adolescent Medicine 2021; 68 (2): 426–28
- Using the Electronic Health Record to Conduct Adolescent Telehealth Visits in the Time of COVID-19. The Journal of adolescent health : official publication of the Society for Adolescent Medicine 2020
IMPLEMENTATION OF AN INPATIENT REPRODUCTIVE HEALTH SCREENING CONSULT SERVICE
ELSEVIER SCIENCE INC. 2020: S56
View details for Web of Science ID 000506637300107
- Teenager, Parent, and Clinician Perspectives on the Electronic Health Record. Pediatrics 2020
Providers' Perspectives on Adolescent Confidentiality and the Electronic Health Record: A State of Transition.
The Journal of adolescent health : official publication of the Society for Adolescent Medicine
PURPOSE: Electronic health records (EHRs) have led to more transparency and improvements in patient safety, yet electronic access to personal health information can pose significant threats to maintaining confidentiality for adolescents. To date, no studies have explored clinicians' perspectives on EHR functionality and institutional policies related to confidentiality and health information sharing for adolescents aged <18years.METHODS: A Web-based survey was sent out via the national listserv of the Society for Adolescent Health and Medicine. All English-speaking members practicing in the U.S. were eligible to participate. The survey included questions about demographics, EHR functionality, information sharing, and attitudes about confidentiality within the EHR.RESULTS: Participants included 212 clinicians who consented to the survey and used an EHR to document clinical visits with minors. Most participants were physicians and nurse practitioners (96.5%), and 60.0% had been on their institution's EHR for >5years. Positive findings included high levels of experience and comfort using the EHR and awareness of confidential features within their EHR. However, providers reported lack of training related to confidentiality within the EHR, low confidence in their EHR's ability to maintain confidentiality, and variation in approaches to portal access for adolescents and their adult proxies.CONCLUSIONS: Despite high comfort levels and robust EHR functionality at many institutions, significant concerns about adolescent confidentiality remain. Varying institutional approaches to protecting confidentiality underscores the need for a standardized and comprehensive framework to enable providers and institutions to take better care of adolescents in the age of EHRs.
View details for DOI 10.1016/j.jadohealth.2019.09.020
View details for PubMedID 31831320
- EFFECTS OF PARTICIPATION IN AN INPATIENT REPRODUCTIVE HEALTH CONSULT SERVICE ON PEDIATRIC RESIDENTS' COMPETENCE IN PROVIDING REPRODUCTIVE CARE FOR ADOLESCENTS AND YOUNG ADULTS ELSEVIER SCIENCE INC. 2019: S86
Contraception for Adolescents and Young Adults in the Inpatient Setting: The Providers' Perspective.
To assess pediatric providers' attitudes and barriers to initiating a contraceptive method in the inpatient setting.Pediatric attending physicians and trainees from 5 academic institutions were surveyed about contraceptive prescribing practices, attitudes, and potential barriers to initiating contraception in the inpatient setting.In 2016, 271 pediatric providers (34.0% were attending physicians, 18.1% fellows, and 47.9% residents) completed the survey; the response rate was 19.2%. Most participants practiced in both inpatient and outpatient settings (95.7% and 85.0%, respectively). More providers felt confident screening for sexual activity among young adults as compared with adolescents (71.9% vs 65.6%). The same was true for discussing contraceptive options (44.0% vs 38.8%, respectively). Inpatient providers reported seeing adolescents and young adults privately, discussing confidentiality, and asking about sex less than half of the time. More than 80% of providers agreed that it would be appropriate to initiate a contraceptive method for inpatients; 35.8% had done so, and 85.2% indicated that having additional consultation would increase initiation of a contraceptive method in the hospital (88.1% felt similarly for long-active reversible contraception methods). General barriers to initiating contraception included insufficient training, insufficient exposure to adolescents and young adults to maintain skills, and lack of time. Barriers specific to the inpatient setting included concerns about follow-up, confidentiality, and interference with the treatment plan.Initiation of a contraceptive method in the inpatient setting is acceptable to providers. In our findings, it is suggested that strategies are needed to enhance provision of these services by addressing confidentiality concerns and educating providers.
View details for PubMedID 29496729
Adolescent Oral Sex and Condom Use: How Much Should We Worry and What Can We Do?
The Journal of adolescent health : official publication of the Society for Adolescent Medicine
2018; 62 (4): 363–64
View details for PubMedID 29571434
- PROVIDERS' ATTITUDES, BELIEFS, AND BARRIERS REGARDING INITIATION OF HORMONAL CONTRACEPTION FOR ADOLESCENT AND YOUNG ADULTS IN THE INPATIENT SETTING ELSEVIER SCIENCE INC. 2017: S114–S115
With Pills, Patches, Rings, and Shots: Who Still Uses Condoms? A Longitudinal Cohort Study
JOURNAL OF ADOLESCENT HEALTH
2013; 52 (1): 77-82
To describe women's condom use patterns over time and assess predictors of dual method use 12 months after initiating hormonal contraceptives.We conducted a prospective cohort study among women aged 15-24 years initiating oral contraceptive pills, patch, ring, or depot medroxyprogesterone and attending public family planning clinics. Participants completed questionnaires at baseline and 3, 6, and 12 months after enrollment. We used multivariable logistic regression to assess baseline factors associated with dual method use at 12 months among 1,194 women who were sexually active in the past 30 days.At baseline, 36% were condom users, and only 5% were dual method users. After initiation of a hormonal method, condom use decreased to 27% and remained relatively unchanged thereafter. Dual method use increased to a peak of 20% at 3 months but decreased over time. Women who were condom users at baseline had nearly twice the odds of being a dual method user at 12 months compared with nonusers (adjusted odds ratio [AOR] = 2.01, 95% CI: 1.28-3.14). Women who believed their main partner thought condoms were "very important," regardless of perceived sexually transmitted infection risk or participant's own views of condoms, had higher odds of dual method use (AOR = 2.89, 95% CI: 1.47-5.71).These results highlight a potential missed opportunity for family planning providers. Providers focus on helping women initiate hormonal methods, however, they may improve outcomes by giving greater attention to method continuation and contingency planning in the event of method discontinuation and to the role of the partner in family planning.
View details for DOI 10.1016/j.jadohealth.2012.08.001
View details for Web of Science ID 000312850500011
View details for PubMedID 23260838
View details for PubMedCentralID PMC3745283