Progress and challenges: implementation and use of health information technology among critical-access hospitals

Community social vulnerability and the 340B Drug Pricing Program: Evaluating predictors of 340B participation among critical access hospital

PURPOSE

The federal 340B Drug Pricing Program allows eligible hospitals, including critical access hospitals (CAHs), to obtain outpatient drugs at a discounted rate. CAHs likely benefit from 340B participation because they are often under-resourced and serve at-risk patient populations. The objective of this study was to understand predictors of 340B program participation among CAHs, and how participation varies with community-level social vulnerability.

METHODS

We used a cross-sectional study design to assess the relationship between 340B participation in 2019 and community vulnerability status using 2018 data from the CDC's social vulnerability index (SVI) among acute care CAHs. Analyses used linear probability models adjusted for hospital-level characteristics.

FINDINGS

In bivariate analyses, CAHs participating in the 340B program had lower overall social vulnerability scores, relative to nonparticipating, eligible, and ineligible CAHs, respectively (43.8 vs. 48.7 vs. 64.7, p < 0.10). In adjusted regression models, greater community vulnerability rankings due to socioeconomic status (-0.129, p < 0.05) and minority status and language (-0.092, p < 0.05) were associated with decreased 340B participation. Higher hospital operating margin was associated with increased 340B participation (0.163, p < 0.05). Although the number of for-profit CAHs ineligible for 340B was small, they had the highest community-level social vulnerability score and lowest hospital operating margin on average.

CONCLUSIONS

CAHs located in areas of high community vulnerability are less likely to participate in the 340B program. Some vulnerable patient populations served by CAHs may be excluded from 340B program benefits.

Management Opportunities and Challenges After Achieving Widespread Health System Digitization

The adoption of electronic health records (EHRs) and digitization of health data over the past decade is ushering in the next generation of digital health tools that leverage artificial intelligence (AI) to improve varied aspects of health system performance. The decade ahead is therefore shaping up to be one in which digital health becomes even more at the forefront of health care delivery - demanding the time, attention, and resources of health care leaders and frontline staff, and becoming inextricably linked with all dimensions of health care delivery. In this chapter, we look back and look ahead. There are substantive lessons learned from the first era of large-scale adoption of enterprise EHRs and ongoing challenges that organizations are wrestling with - particularly related to the tension between standardization and flexibility/customization of EHR systems and the processes they support. Managing this tension during efforts to implement and optimize enterprise systems is perhaps the core challenge of the past decade, and one that has impeded consistent realization of value from initial EHR investments. We describe these challenges, how they manifest, and organizational strategies to address them, with a specific focus on alignment with broader value-based care transformation. We then look ahead to the AI wave - the massive number of applications of AI to health care delivery, the expected benefits, the risks and challenges, and approaches that health systems can consider to realize the benefits while avoiding the risks.

Electronic medical record use and associated factors among healthcare professionals at public health facilities in Dire Dawa, eastern Ethiopia: A mixed-method study

Background

Despite the significant benefits of digital health technologies (ITs), developing countries are lagging behind their developed counterparts in the adoption of electronic medical records (EMRs) in a healthcare setting. EMRs have long been considered essential elements in improving the quality of healthcare. However, the rate of utilization of EMRs among healthcare providers still remains low, particularly in developing countries.

Objective

This study aimed at exploring EMR use and its determinants among healthcare providers at public health facilities in Dire Dawa, eastern Ethiopia.

Methods

A quantitative cross-sectional study was conducted among 402 health professionals working at public health facilities supplemented with an exploratory qualitative study in Dire Dawa, Ethiopia. Descriptive summary statistics and binary and multivariable logistic regression analysis were used to explore the determinant factors of EMR use, while qualitative data were thematically analyzed.

Results

Overall, about a quarter (26.6%) of health professionals were using electronic medical records. A work experience of 6 years or less [adjusted odds ratio (AOR) = 2.23; 95% confidence interval (CI): [1.15–4.31]], a discussion on EMR (AOR = 14.47; 95% CI: [5.58–7.57]), the presence of an EMR manual (AOR = 3.10; 95% CI: [1.28–7.38]), and a positive attitude toward the EMR system (AOR = 11.15; 95% CI: [4.90–25.36]) and service quality (AOR = 8.02; 95% CI: [4.09–15.72]) were independent determinants of EMR use. Poor collaboration among stakeholders and dependence on the software programs of NGOs were the main challenges cited by key informants.

Conclusion

The findings of this study indicate that EMR use by health professionals in the study area is very low. Several organizational, technical, and behavioral factors were identified for this low utilization. Therefore, there is a need to leverage EMRs through continuous technical support and commitment to enhance its use, which has the potential to improve health service performance. Developing locally applicable EMR software should be considered.

Limited-Montage EEG as a Tool for the Detection of Nonconvulsive Seizures

PURPOSE

Prefabricated arrays with a limited number of electrodes offer an opportunity to hasten the diagnosis of seizures; however, their accuracy to detect seizures is unknown. We examined the utility of two limited-montage EEG setups for the detection of nonconvulsive seizures.

METHODS

Thirty previously interpreted EEG segments with nonconvulsive seizures from 30 patients and 60 segments with background slowing or normal EEG from 60 patients were rendered in a bipolar "double banana" montage, a double distance "neonatal" montage, and a circumferential "hatband" montage. Experts reviewed 60 to 180 seconds long segments to determine whether seizures were present and if the EEG data provided were sufficient to make a decision on escalation of clinical care by ordering an additional EEG or prescribing anticonvulsants. The periodic patterns on the ictal-interictal continuum were specifically excluded for this analysis to keep the focus on definite electrographic seizures.

RESULTS

The sensitivities for seizure of the neonatal and hatband montages were 0.96 and 0.84, respectively, when compared with full montage EEG, whereas the specificities were 0.94 and 0.98, respectively. Appropriate escalation of care was suggested for 96% and 92% of occurrences of seizure patterns in neonatal and hatband montages, respectively. When compared with clinical EEG, the sensitivities of the neonatal and hatband montages for seizure diagnosis were 0.85 and 0.69, respectively.

CONCLUSIONS

Nonconvulsive seizures were detected with high accuracy using the limited electrode array configuration in the neonatal and hatband montages. The sensitivity of the neonatal montage EEG in detecting seizures was superior to that of a hatband montage. These findings suggest that in some patients with nonconvulsive seizures, limited-montage EEG may allow to differentiate ictal and slow patterns.

The use of information and communication technology in Japanese rural clinics

High-speed information and communication technology (ICT) networks stretch all over Japan. However, their utility in facilitating rural healthcare remains uncharacterized. A nationwide questionnaire survey was sent by mail to 1,018 rural clinics constructed in a public manner in municipalities throughout Japan. ICT use was classified by type, including a doctor-to-doctor manner. Only 19% of the 303 clinics surveyed (with a response rate of 30%) used ICT. Specifically, 50% used it in a doctor-to-doctor manner, while 35% used it to obtain electronic medical records. Differences in proficiency levels among ICT users were cited by 21% of the respondents as a major problem associated with ICT use. In Japan, the prevalence of ICT use for rural healthcare appeared low. We suggest a policy reform to facilitate ICT use in rural healthcare.

A decade post-HITECH: Critical access hospitals have electronic health records but struggle to keep up with other advanced functions

OBJECTIVE

Despite broad electronic health record (EHR) adoption in U.S. hospitals, there is concern that an "advanced use" digital divide exists between critical access hospitals (CAHs) and non-CAHs. We measured EHR adoption and advanced use over time to analyzed changes in the divide.

MATERIALS AND METHODS

We used 2008 to 2018 American Hospital Association Information Technology survey data to update national EHR adoption statistics. We stratified EHR adoption by CAH status and measured advanced use for both patient engagement (PE) and clinical data analytics (CDA) domains. We used a linear probability regression for each domain with year-CAH interactions to measure temporal changes in the relationship between CAH status and advanced use.

RESULTS

In 2018, 98.3% of hospitals had adopted EHRs; there were no differences by CAH status. A total of 58.7% and 55.6% of hospitals adopted advanced PE and CDA functions, respectively. In both domains, CAHs were less likely to be advanced users: 46.6% demonstrated advanced use for PE and 32.0% for CDA. Since 2015, the advanced use divide has persisted for PE and widened for CDA.

DISCUSSION

EHR adoption among hospitals is essentially ubiquitous; however, CAHs still lag behind in advanced use functions critical to improving care quality. This may be rooted in different advanced use needs among CAH patients and lack of access to technical expertise.

CONCLUSIONS

The advanced use divide prevents CAH patients from benefitting from a fully digitized healthcare system. To close the widening gap in CDA, policymakers should consider partnering with vendors to develop implementation guides and standards for functions like dashboards and high-risk patient identification algorithms to better support CAH adoption.

Hospital adoption of multiple health information exchange approaches and information accessibility

OBJECTIVE

Hospital engagement in electronic health information exchange (HIE) has increased over recent years. We aimed to 1) determine the change in adoption of 3 types of information exchange: secure messaging, provider portals, and use of an HIE; and 2) to assess if growth in each approach corresponded to increased ability to access and integrate patient information from outside providers.

METHODS

Panel analysis of all nonfederal, acute care hospitals in the United States using hospital- and year-fixed effects. The sample consisted of 1917 hospitals that responded to the American Hospital Association Information Technology Supplement every year from 2014 to 2016.

RESULTS

Adoption of each approach increased by 9-15 percentage points over the study period. The average number of HIE approaches used by each hospital increased from 1.0 to 1.4. Adoption of each approach was associated with increased likelihood that providers routinely had necessary outside information of 4.2-12.7 percentage points and 4.5-13.3 percentage points increase in information integration. Secure messaging was associated with the largest increase in both. Adoption of 1 approach increased the likelihood of having outside information by 10.3 percentage points, while adopting a second approach further increased the likelihood by 9.5 percentage points. Trends in number of approaches and integration were similar.

DISCUSSION/CONCLUSION

No single HIE tool provided high levels of usable, integrated health information. Instead, hospitals benefited from adopting multiple tools. Policy initiatives that reduce the complexity of enabling high value HIE could result in broader adoption of HIE and use of information to inform care.

Hospital Characteristics Associated with Certified EHR Adoption among US Psychiatric Hospitals

Objective

The aim of this study was to explore the relationship between hospital characteristics and certified electronic health record (EHR) adoption in psychiatric hospitals in the US.

Methods

Data were drawn from the American Hospital Association Annual Survey Database and the Centers for Medicare and Medicaid Services Hospital Compare data sets in 2016. Binary logistic regression analysis and χ² tests were performed to examine the relationship between certified EHR adoption and hospital characteristics.

Results

Of 1,059 psychiatric hospitals in the US, 502 (47.4%) have adopted certified EHR technology. Large hospitals (OR 2.29, 95% CI 1.52–3.44; p<0.001), not-for-profit hospitals (OR 1.74, 95% CI 1.22–2.49; p=0.008), and hospitals participating in a network (OR 1.78, 95% CI 1.34–2.37; p<0.001) were more likely to adopt certified EHRs. Hospitals in the northeast were less likely to implement certified EHRs compared to other regions. However, there was no significant association found between EHR utilization and system affiliation, urban location, teaching status, or participation of health-maintenance organizations and preferred provider organizations.

Conclusion

The study results suggested variations in EHR adoption according to hospital location, size, ownership, and network participation. This study fills a gap in previous work on certified EHR adoption that focused exclusively on general hospitals, but overlooked psychiatric hospitals. Future policies designed to influence the implementation of certified EHRs should take into consideration how hospital size, ownership, and network-affiliation status affect certified EHR adoption among psychiatric hospitals.

The adoption of electronic medical record by physicians: A PRISMA-compliant systematic review

BACKGROUND

The electronic medical record (EMR) is considered to be a vital tool of information and communication technology (ICT) to improve the quality of medical care, but the limited adoption of EMR by physicians results in a considerable warning to its successful implementation. The purpose of the present review is to explore and identify the potential barriers perceived by physicians in the adoption of EMR.

METHODS

The systematic review was carried out based on literature published in 5 databases: PubMed, Web of Science, Scopus, The Cochrane Library, and ProQuest from 2014 to 2018, concerning barriers perceived by physicians to the adoption of EMR.

RESULTS

The present study incorporates 26 articles based on their appropriateness out of 1354 for the final analysis. Authors explore 25 barriers that appeared 112 times in the literature for the present review; the top 5 frequently mentioned barriers are privacy and security concerns, high start-up cost, workflow changes, system complexity, lack of reliability, and interoperability.

CONCLUSION

The systematic review explores that physicians deal with different barriers as they intend to adopt EMR. The barriers explored in the present review are the potential to play as references for the implementer of the EMR system. Thus an attentive analysis of the definitive condition is needed before relevant intervention is determined as the implementation of EMR must be considered as a behavioral change in medical practice.

Multiyear Performance Trends Analysis of Primary Care Practices Demonstrating Patient-Centered Medical Home Transformation: An Observation of Quality Improvement Indicators among Outpatient Clinics

Despite the ever-changing requirements of modern policy, payers seek interventions for care delivery improvement through value-based care models. Prior research acknowledges the Patient-Centered Medical Home (PCMH) as a tool for performance and outcomes improvement. However, these studies lack empirical evidence of performance trends across medical homes. A retrospective observational study was conducted to describe national trends in National Committee for Quality Assurance PCMH recognition for more than 23 000 primary care practices across the United States from 2008 to 2017. More than half of recognized practices scored 100% pass rates for activities related to appointment availability, patient care planning, and data for population management. The most common underperforming PCMH activities were for practice team, referral tracking and follow-up, and quality improvement implementation. Study findings indicate that patient-centered care collaboration between clinical and nonclinical team members, primary care provider coordination with specialty care providers, and practice implementation of clinical quality improvement methodologies are particularly challenging activities.

Telestroke Adoption Among Community Hospitals in North Carolina: A Cross-Sectional Study

OBJECTIVE

This study identifies community and hospital characteristics associated with adoption of telestroke among acute care hospitals in North Carolina (NC).

METHODS

Our sample included 107 hospitals located in NC. Our analytic dataset included variables from the American Hospital Association (AHA) annual survey, AHA Health IT supplement, Healthcare Cost Report Information System, and Centers for Disease Control and Prevention's WONDER online database. We supplemented our secondary sources with data on telestroke adoption and market-level variables developed for NC. We used the Consolidated Framework for Implementation Research and previous telehealth studies to guide selection of variables. We conducted a multivariate logistic regression to determine associations with telestroke adoption.

RESULTS

Proportion of discharges that are Medicare (odds ratio [OR] = 1.93, P < .04) and total operating margin (OR = 2.89, P = .00) were positively associated with telestroke adoption. Critical access hospital status was positively associated with telestroke adoption, although not at P < .05 (OR = 5.61, P = .07). Distance to the nearest hospital with a telestroke program (OR = .91, P = .01) and volume of emergency department visits (OR = .98, P < .05) were both negatively associated with telestroke adoption.

CONCLUSIONS

Our study is novel in its focus on telestroke adoption and use of variables not included in previous telehealth analyses. Our findings suggest some hospitals have neither the financial resources nor the ability to pool resources for acquiring needed technology, and differences in adoption may result in geographic inequities in access to telestroke services.

Factors Determining the Success and Failure of eHealth Interventions: Systematic Review of the Literature

Background

eHealth has an enormous potential to improve healthcare cost, effectiveness, and quality of care. However, there seems to be a gap between the foreseen benefits of research and clinical reality.

Objective

Our objective was to systematically review the factors influencing the outcome of eHealth interventions in terms of success and failure.

Methods

We searched the PubMed database for original peer-reviewed studies on implemented eHealth tools that reported on the factors for the success or failure, or both, of the intervention. We conducted the systematic review by following the patient, intervention, comparison, and outcome framework, with 2 of the authors independently reviewing the abstract and full text of the articles. We collected data using standardized forms that reflected the categorization model used in the qualitative analysis of the outcomes reported in the included articles.

Results

Among the 903 identified articles, a total of 221 studies complied with the inclusion criteria. The studies were heterogeneous by country, type of eHealth intervention, method of implementation, and reporting perspectives. The article frequency analysis did not show a significant discrepancy between the number of reports on failure (392/844, 46.5%) and on success (452/844, 53.6%). The qualitative analysis identified 27 categories that represented the factors for success or failure of eHealth interventions. A quantitative analysis of the results revealed the category quality of healthcare (n=55) as the most mentioned as contributing to the success of eHealth interventions, and the category costs (n=42) as the most mentioned as contributing to failure. For the category with the highest unique article frequency, workflow (n=51), we conducted a full-text review. The analysis of the 23 articles that met the inclusion criteria identified 6 barriers related to workflow: workload (n=12), role definition (n=7), undermining of face-to-face communication (n=6), workflow disruption (n=6), alignment with clinical processes (n=2), and staff turnover (n=1).

Conclusions

The reviewed literature suggested that, to increase the likelihood of success of eHealth interventions, future research must ensure a positive impact in the quality of care, with particular attention given to improved diagnosis, clinical management, and patient-centered care. There is a critical need to perform in-depth studies of the workflow(s) that the intervention will support and to perceive the clinical processes involved.

Do Years of Experience With Electronic Health Records Matter for Productivity in Community Health Centers?

This study investigated how years of experience with an electronic health record (EHR) related to productivity in community health centers (CHCs). Using data from the 2012 Uniform Data System, we regressed average annual medical visits, weighted for service intensity, as a function of full-time equivalent medical staff controlling for CHC size and location. Physician productivity significantly improved. Although the productivity of all other staff types was not significantly different by years of EHR experience, the trends showed lower productivity among nurses and other medical staff in CHCs with fewer years of EHR experience versus more years of experience.

Barriers to Electronic Health Record Adoption: a Systematic Literature Review

Federal efforts and local initiatives to increase adoption and use of electronic health records (EHRs) continue, particularly since the enactment of the Health Information Technology for Economic and Clinical Health (HITECH) Act. Roughly one in four hospitals not adopted even a basic EHR system. A review of the barriers may help in understanding the factors deterring certain healthcare organizations from implementation. We wanted to assemble an updated and comprehensive list of adoption barriers of EHR systems in the United States. Authors searched CINAHL, MEDLINE, and Google Scholar, and accepted only articles relevant to our primary objective. Reviewers independently assessed the works highlighted by our search and selected several for review. Through multiple consensus meetings, authors tapered articles to a final selection most germane to the topic (n = 27). Each article was thoroughly examined by multiple authors in order to achieve greater validity. Authors identified 39 barriers to EHR adoption within the literature selected for the review. These barriers appeared 125 times in the literature; the most frequently mentioned barriers were regarding cost, technical concerns, technical support, and resistance to change. Despite federal and local incentives, the initial cost of adopting an EHR is a common existing barrier. The other most commonly mentioned barriers include technical support, technical concerns, and maintenance/ongoing costs. Policy makers should consider incentives that continue to reduce implementation cost, possibly aimed more directly at organizations that are known to have lower adoption rates, such as small hospitals in rural areas.

A literature review for large-scale health information system project planning, implementation and evaluation

Information technology is perceived as a potential panacea for healthcare organisations to manage pressure to improve services in the face of increased demand. However, the implementation and evaluation of health information systems (HIS) is plagued with problems and implementation shortcomings and failures are rife. HIS implementation is complex and relies on organisational, structural, technological, and human factors to be successful. It also requires reflective, nuanced, multidimensional evaluation to provide ongoing feedback to ensure success. This article provides a comprehensive review of the literature about evaluating and implementing HIS, detailing the challenges and recommendations for both evaluators and healthcare organisations. The factors that inhibit or promote successful HIS implementation are identified and effective evaluation strategies are described with the goal of informing teams evaluating complex HIS.

Assessing HITECH Implementation and Lessons: 5 Years Later

POLICY POINTS

The expansive goals of the Health Information Technology for Economic and Clinical Health (HITECH) Act required the simultaneous development of a complex and interdependent infrastructure and a wide range of relationships, generating points of vulnerability. While federal legislation can be a powerful stimulus for change, its effectiveness also depends on its ability to accommodate state and local policies and private health care markets. Ambitious goals require support over a long time horizon, which can be challenging to maintain. The future of health information technology (health IT) support nationally is likely to depend on the ability of the technology to satisfy its users that its functionalities address the interests policymakers and other stakeholders have in using technology to promote better care, improved outcomes, and reduced costs.

CONTEXT

The Health Information Technology for Economic and Clinical Health (HITECH) Act set ambitious goals for developing electronic health information as one tool to reform health care delivery and improve health outcomes. With HITECH's grant funding now mostly exhausted but statutory authority for standards remaining, this article looks back at HITECH's experience in the first 5 years to assess its implementation, remaining challenges, and lessons learned.

METHODS

This review derives from a global assessment of the HITECH Act. Earlier, we examined the logic of HITECH and identified interdependencies critical to its ultimate success. In this article, we build on that framework to review what has and has not been accomplished in building the infrastructure authorized by HITECH since it was enacted. The review incorporates quantitative and qualitative evidence of progress from the global assessment and from the evaluations funded by the Office of the National Coordinator for Health Information Technology (ONC) of individual programs authorized by the HITECH Act.

FINDINGS

Our review of the evidence provides a mixed picture. Despite HITECH's challenging demands, its complex programs were implemented, and important changes sought by the act are now in place. Electronic health records (EHRs) now exist in some form in most professional practices and hospitals eligible for HITECH incentive payments, more information is being shared electronically, and the focus of attention has shifted from adoption of EHRs toward more fundamental issues associated with using health information technology (health IT) to improve health care delivery and outcomes. In some areas, HITECH's achievements to date have fallen short of the hopes of its proponents as it has proven challenging to move meaningful use beyond the initial low bar set by Meaningful Use Stage 1. EHR products vary in their ability to support more advanced functionalities, such as patient engagement and population-based care management. Many barriers to interoperability persist, limiting electronic communication across a diverse set of largely private providers and care settings.

CONCLUSIONS

Achieving the expansive goals of HITECH required the simultaneous development of a complex and interdependent infrastructure and a wide range of relationships, some better positioned to move forward than others. To date, it has proven easier to get providers to adopt EHRs, perhaps in response to financial incentives to do so, than to develop a robust infrastructure that allows the information in EHRs to be used effectively and shared not only within clinical practices but also across providers. Effective exchange of data is necessary to drive the kinds of delivery and payment reforms sought nationwide.

Electronic Health Record Adoption In US Hospitals: Progress Continues, But Challenges Persist

Achieving nationwide adoption of electronic health records (EHRs) remains an important policy priority. While EHR adoption has increased steadily since 2010, it is unclear how providers that have not yet adopted will fare now that federal incentives have converted to penalties. We used 2008-14 national data, which includes the most recently available, to examine hospital EHR trends. We found large gains in adoption, with 75 percent of US hospitals now having adopted at least a basic EHR system--up from 59 percent in 2013. However, small and rural hospitals continue to lag behind. Among hospitals without a basic EHR system, the function most often not yet adopted (in 61 percent of hospitals) was physician notes. We also saw large increases in the ability to meet core stage 2 meaningful-use criteria (40.5 percent of hospitals, up from 5.8 percent in 2013); much of this progress resulted from increased ability to meet criteria related to exchange of health information with patients and with other physicians during care transitions. Finally, hospitals most often reported up-front and ongoing costs, physician cooperation, and complexity of meeting meaningful-use criteria as challenges. Our findings suggest that nationwide hospital EHR adoption is in reach but will require attention to small and rural hospitals and strategies to address financial challenges, particularly now that penalties for lack of adoption have begun.

Inclusion of dynamic clinical data improves the predictive performance of a 30-day readmission risk model in kidney transplantation

BACKGROUND

Thirty-day readmissions (30DRA) are a highly scrutinized measure of healthcare quality and relatively frequent among kidney transplants (KTX). Development of predictive risk models is critical to reducing 30DRA and improving outcomes. Current approaches rely on fixed variables derived from administrative data. These models may not capture clinical evolution that is critical to predicting outcomes.

METHODS

We directed a retrospective analysis toward: (1) developing parsimonious risk models for 30DRA and (2) comparing efficiency of models based on the use of immutable versus dynamic data. Baseline and in-hospital clinical and outcomes data were collected from adult KTX recipients between 2005 and 2012. Risk models were developed using backward logistic regression and compared for predictive efficacy using receiver operating characteristic curves.

RESULTS

Of 1147 KTX patients, 123 had 30DRA. Risk factors for 30DRA included recipient comorbidities, transplant factors, and index hospitalization patient level clinical data. The initial fixed variable model included 9 risk factors and was modestly predictive (area under the curve, 0.64; 95% confidence interval [95% CI], 0.58-0.69). The model was parsimoniously reduced to 6 risks, which remained modestly predictive (area under the curve, 0.63; 95% CI, 0.58-0.69). The initial predictive model using 13 fixed and dynamic variables was significantly predictive (AUC, 0.73; 95% CI, 0.67-0.80), with parsimonious reduction to 9 variables maintaining predictive efficacy (AUC, 0.73; 95% CI, 0.67-0.79). The final model using dynamically evolving clinical data outperformed the model using static variables (P=0.009). Internal validation demonstrated that the final model was stable with minimal bias.

CONCLUSIONS

We demonstrate that modeling dynamic clinical data outperformed models using immutable data in predicting 30DRA.