Association of an Electronic Health Record Add-on App for Neonatal Bilirubin Management With Physician Efficiency and Care Quality
Authors: Kensaku Kawamoto, Polina Kukhareva, Julie H. Shakib, Heidi Kramer, Salvador Rodriguez, Phillip B. Warner, David Shields, Charlene Weir, Guilherme Del Fiol, Teresa Taft, Carole H. Stipelman
Journal: JAMA Network Open (2019)

<h3>Importance</h3> The usefulness of electronic health record (EHR) systems could be significantly enhanced by innovative, third-party EHR add-on apps. <h3>Objective</h3> To evaluate whether an EHR add-on app for neonatal bilirubin management can save clinicians time and improve patient care. <h3>Design, Setting, and Participants</h3> This quality improvement study was conducted at the University of Utah Health Well Baby nursery and outpatient clinics and consisted of 4 substudies: (1) time savings were estimated in an experimental task-timing study comparing the time required for physicians to manage newborns' bilirubin levels with and without the add-on app, (2) app use was estimated from app logs, (3) health care use measures and guideline compliance were compared retrospectively before and after the intervention, and (4) clinician-perceived usability was measured through System Usability Scale surveys. The study took place between April 1, 2016, and September 3, 2019. Data analyses were conducted from October 30, 2018, to September 23, 2019. <h3>Interventions</h3> At baseline, clinicians used a manual approach to ensure compliance with an evidence-based clinical guideline for neonatal bilirubin management. To facilitate guideline compliance, an EHR add-on app that automatically retrieves, organizes, and visualizes relevant patient data was developed. The app provides patient-specific assessments and recommendations, including the risk of rebound hyperbilirubinemia following phototherapy based on a predictive model. The add-on app was integrated with the University of Utah Health EHR on April 12, 2017. <h3>Main Outcomes and Measures</h3> Clinician time savings, app use, health care use measures, guideline-compliant phototherapy ordering, and perceived usability as measured by the System Usability Scale survey. The survey is composed of 10 statements with responses ranging from 1 (strongly disagree) to 5 (strongly agree). The survey results in a single score ranging from 0 to 100, with ratings described as worst imaginable (mean System Usability Scale score, 12.5), awful (20.3), poor (35.7), okay (50.9), good (71.4), excellent (85.5), and best imaginable (90.9). <h3>Results</h3> In 2018, the application was used 20 516 times by clinicians for 91.84% of eligible newborns. Use of the app saved 66 seconds for bilirubin management tasks compared with a commonly used tool (95% CI, 53-79 seconds;<i>P</i> &lt; .001). Following the intervention, health care use rates remained stable, while orders for clinically appropriate phototherapy during hospitalization increased for newborns with bilirubin levels above the guideline-recommended threshold (odds ratio, 1.84; 95% CI, 1.16-2.90;<i>P</i> = .009). Surveys indicated excellent usability (System Usability Scale score, 83.90; 95% CI, 81.49-86.31). <h3>Conclusions and Relevance</h3> Well-designed EHR add-on apps may save clinicians time and improve patient care. If time-saving apps, such as the bilirubin app, were implemented widely across institutions and care domains, the potential association with improved patient care and clinician efficiency could be significant. The University of Utah Health bilirubin app is being prepared for release into EHR app stores as free-to-use software.