Collaborative Research from MedStar Investigators Evaluate On-Demand Telehealth COVID Screening

A collaborative team of researchers from across MedStar Health recently published research evaluating the performance of on-demand telehealth as an approach to respond to COVID-19. The team included investigators from MedStar Health National Center for Human Factors in Healthcare, MedStar Telehealth Innovation Center and the MedStar Institute for Innovation.

“A Descriptive Analysis of an On-Demand Telehealth Approach for Remote COVID-19 Patient Screening” was published in Journal of Telemedicine and Telecare. The analysis presented by the investigators covers telehealth patient characteristics, measures of patient wait time and visit duration, technical success of the telehealth request and the post-visit trajectory of these patients.

The study evaluated 9,270 on-demand telehealth requests from 7,112 unique patients from March to April 2020.  Each telehealth request was categorized as either a completed encounter in which the patient successfully saw the provider and was given clinical guidance, or an incomplete request in which the patient did not complete an encounter with the provider. For completed encounters, additional analyses were performed, and the patient was provided a survey and asked what they would have done if on-demand telehealth was unavailable.

The results show that out of the over 7,000 unique patients with on-demand telehealth requests, the average patient age was around 38 years old, 4,511 were female and 2,601 were male. Most requests (61.6%) had a visit reason categorized as likely COVID-19 related. The majority (79%) of likely COVID-19 related requests were completed encounters and of these, 19% were referred for in-person care or testing. The average completed encounter wait time was 26 minutes. In addition, there were 1194 requests that were categorized as left without being seen. The average wait time for patients that left without being seen was 19 minutes.

The post-encounter survey, for patients who had a completed visit, indicated that 26% of patients would have gone to an urgent care or retail clinic if on-demand telehealth was unavailable. There were 482 patients (10.7%) who said they would go to their doctor’s office and 267 (5.9%) would go to the ER. The survey showed 9.1% of patients would not have done anything.  There was no response from 48% of completed encounters.

The research concluded that on-demand telehealth service can serve an important public health need in response to the COVID-19 pandemic. According to the survey, 1935 (42.8% of the 4518 COVID-19 related requests) patients would have sought in-person care had they not had access to on-demand telehealth.  There were several patients who stated they would have done nothing about their concerns. On-demand telehealth helps to decrease personal exposure and demonstrates a low-barrier approach to screening patients for COVID-19.

The research team included MedStar Health’s Raj Ratwani, PhD; David Brennan; Bill Sheahan; Allan Fong; Katharine Adams; Allyson Gordon; Mary Calabrese; Elizabeth Hwang; Mark Smith, MD; and Ethan Booker, MD.

Journal of Telemedicine and Telecare, 2020. DOI: 10.1177/1357633X20943339

MedStar Researchers Evaluate Outcomes in Patients Undergoing ACL Repair

Researchers at MedStar Health sought to assess failure rate, outcomes, and patient satisfaction in patients who underwent anterior cruciate ligament (ACL) repair with suture augmentation for clinical instability and proximal avulsion of the ACL. ACL avulsion fractures have a high incidence in most injuries around the knee joint. Improved surgical technology, rehabilitation principles, and minimally invasive surgical techniques have led to renewed interest in primary ACL repair.

“Anterior Cruciate Ligament Repair with Suture Augmentation for Proximal Avulsion Injurieswas recently published in Arthroscopy, Sports Medicine, and Rehabilitation. The research team retrospectively reviewed suture-augmented ACL repairs performed by a single surgeon between January 2014 and June 2016 for proximal ACL avulsion. Patients were followed in the office until they were released to return to unrestricted activity. All patients were contacted by phone to collect data such as recurrent clinical instability, number of reoperations, reason for reoperation, and return to sport or previous activity level. An automated database was used to collect functional and clinical outcomes scores. 

The team hypothesized they would find significantly improved functional outcome and a high percentage of patients who exceeded the minimum clinically important difference (MCID) and patient acceptable symptom state (PASS) threshold for ACL surgery. The PASS threshold for Knee Injury and Osteoarthritis Outcome Score (KOOS) components in patients who underwent ACL reconstruction has been reported as pain, 88.9%; symptoms, 57.1%; activities of daily living (ADL), 100%; sport/recreation, 75%; and quality of life (QoL), 62.5%.

Of 172 patients who underwent ACL surgery during the study period, 28 (16%) underwent ACL repair with suture augmentation. One patient was unavailable for follow-up.   Of these 27 patients, 17 were diagnosed with Sherman type I tear and 10 were diagnosed with Sherman type II tear. All 27 patients available for follow-up had post-operative scores, and 14 patients had preoperative scores. Of the 27 patients, 4 recurrent ACL injuries required revision to reconstruction. The remaining 23 patients had successful ACL repair with no clinical instability and no subjective complaints at final follow-up. The results include 11 patients with baseline data, demonstrating significant improvements in KOOS score and final follow-up score in relation to the MCID for that instrument: pain (73%), symptoms (100%), ADL (64%), sport and recreation (80%), and quality of life (45%).

The research concludes that patients with proximal ACL avulsion, ACL repair with suture augmentation demonstrated high functional outcome and improved patient-reported outcomes at 2-year follow-up. This procedure shows promise for treating patients with clinical instability from proximal ACL avulsion.

The study team included Wiemi A. Douoguih, M.D.; Ralph T. Zade, M.D.; Blake M. Bodendorfer, M.D.; Yalda Siddiqui, B.S.; and Andrew E. Lincoln, D.P.H.

August Peer-Reviewed Publications from MedStar Health

Congratulations to all MedStar researchers who had articles published in August 2020. The selected articles and link to PubMed provided below represent the body of work completed by MedStar Health investigators, physicians, and associates and published in peer-reviewed journals last month. The list is compiled from PubMed for any author using “MedStar” in the author affiliation. Congratulations to this month’s authors. We look forward to seeing your future research.

View the full list of publications on here.

  1. Epidemiology, Treatment, and Performance-Based Outcomes in American Professional Baseball Players With Symptomatic Spondylolysis and Isthmic Spondylolisthesis
    The American Journal of Sports Medicine, 2020. DOI: 10.1177/0363546520945727
    Gould HP, Winkelman RD, Tanenbaum JE, Hu E, Haines CM, Hsu WK, Kalfas IH, Savage JW, Schickendantz MS, Mroz TE.

  2. Ethnicity and insurance status predict metastatic disease presentation in prostate, breast, and non-small cell lung cancer
    Cancer Medicine, 2020. DOI: 10.1002/cam4.3109
    Aghdam N, McGunigal M, Wang H, Repka MC, Mete M, Fernandez S, Dash C, Al-Refaie WB, Unger KR.

  3. The IMPact on Revascularization Outcomes of intraVascular ultrasound-guided treatment of complex lesions and Economic impact (IMPROVE) trial: Study design and rationale
    American Heart Journal, 2020. DOI: 10.1016/j.ahj.2020.08.002
    Shlofmitz E, Torguson R, Mintz GS, Zhang C, Sharp A, Hodgson JM, Shah B, Kumar G, Singh J, Inderbitzen B, Weintraub WS, Garcia-Garcia HM, Di Mario C, Waksman R.

  4. Lessons Learned from Caring for Patients with COVID-19 at the End of Life
    Journal of  Palliative Medicine, 2020. DOI: 10.1089/jpm.2020.0251
    Rao A, Kelemen A.

MedStar Health 2020-2021 Mandatory Influenza Vaccinations

The 2020-2021 influenza season will coincide with the COVID-19 pandemic. This inevitable combination will present unique challenges affecting MedStar Health associates and physicians, as well as the communities we serve. This year, more than ever, compliance with our mandatory influenza (flu) vaccination program is essential to achieving our patient and associate safety priorities.

As a reminder, all MedStar Health associates, physicians, residents, students, volunteers, contracted staff, and vendors are required to receive the influenza (flu) vaccination. The vaccination period is Thursday, Oct. 1, 2020 through Wednesday, Dec. 9, 2020. While flu vaccine clinics will be scheduled at a variety of locations across the system, eligible associates and physicians may also receive their vaccination at Occupational Health offices, unit rounds in high-volume patient care areas, and from peer immunizers. New infection prevention protocols, including appropriate Personal Protective Equipment (PPE), frequent disinfection of clipboards, pens and other tools, and physical distancing, will be in place in all flu vaccine clinic locations.

We will continue to provide the vaccine at MedStar Health entities free of cost for associates, physicians, residents, and volunteers. Locations, dates and times for entity clinics will be posted on StarPort ( by Sept. 14, 2020. If individuals choose to be vaccinated at non-MedStar facilities or a MedStar Health Urgent Care location, they must complete and submit official documentation to Occupational Health (letterhead, prescription form, printed receipt, etc.) from the provider administering the vaccine. Documentation must include:

  • Associate's name
  • Date of vaccination
  • Name, dose and lot number of vaccine
  • Name, address and phone number of provider

We recognize that a small percentage of individuals may not be able to receive the flu vaccination due to medical contra-indications and/or religious exemptions. The Influenza Vaccine Exemption Form will need to be obtained from, completed and returned to Occupational Health by Oct. 31, 2020.

While the Centers for Medicare & Medicaid Services (CMS) announced it will not require the typical vaccine compliance data reporting this year, MedStar Health will continue to require all associates, physicians, residents/fellows, volunteers, students, contracted staff, and vendors to receive a flu vaccine before the end of the vaccination period or document exemption by the deadline.

Please share this information with your appropriate stakeholders as a priority topic at town hall meetings, staff meetings, rounds, and other communication touch points.

By collectively vaccinating ourselves against influenza, we enhance patient and associate safety across our organization and communities. Remember, an individual with no flu symptoms may still be a carrier and unknowingly spread it to patients, coworkers, visitors, and family members.

Thank you for your commitment to patient and associate safety through flu vaccination.

Ongoing Cybersecurity Risks – Phishing

Throughout the COVID-19 pandemic, criminals have used the crisis as a basis for increased attacks on computer systems, including phishing campaigns. These attacks are organized and often specifically target healthcare systems or individuals to collect sensitive business or personal information.  

Phishing is a constant threat, but there is also a seasonality to cyberattacks, with more coming during traditional vacation times, when criminals assume defenses are lowered and staffing may vary due to time off. As organizations, including MedStar Health, navigate a new normal, experts anticipate new email phishing attacks attempting to exploit changes, such as adjustments to revised workflows and remote working arrangements.

Associate vigilance is among our best defense strategies for savvy attackers who prompt associates to provide personal information or passwords, click on or open malicious links or attachments, or transfer money. Attacks can come through phishing emails, texts or voice calls to a workstation, smartphone or other device.

Malicious senders may spoof a known source for COVID-19 information, such as the Centers for Disease Control and Prevention (CDC), MedStar Human Resources, or a local school district or government office. Phishing attempts may also come from from vendors purporting to have or sell Personal Protective Equipment (PPE). 

To avoid these risks, always follow these important recommendations: 

  • Take your time when reviewing email or text messages. Use caution before you click!
  • Be alert for phishing messages in your email inbox. Since phishing emails arrive from outside of the network, determine whether the email is legitimate. All external emails include a tag of [EXTERNAL] in the email subject line and a banner:

** ATTENTION: This email originated from outside the MedStar network.
** DO NOT CLICK links or attachments unless you recognize the sender and know the content is safe.

  • If you don’t know the sender and it looks suspicious, delete the email. Do not click on any attachments or links within the body of the email.
  • Look for spoofed addresses. For example, if an email appears to come from an associate and the sender’s address is not, it is not a legitmate email.
  • If you receive a text message from a number you do not know, delete the text message. Do not click on any links within the text message.
  • Report suspicious emails to [email protected]. Call the IS Service Desk at 877-777-8787 with any questions.

Thank you for your efforts to protect our network, data, systems, and organization.

Research Billing Compliance at MedStar Health

Research compliance encompasses a wide variety of issues including research billing. Billing compliance ensures all services in a trial are paid for by helping to reduce double billing and preventing billing for services that are not covered by the trial or are not medically necessary for the research subject. Accurate billing in research is a complex and challenging process that requires a diverse group of professionals across MedStar Health to work cohesively and collaboratively with one another. We at the Research Institute seek to ensure that we have an efficient and compliant approach to billing compliance.

The research coordinators have the most critical step in the clinical research revenue cycle process. Research subject visit tracking directly drives financial management and compliance. This is the first line of defense against erroneous billing. Subject visits must be logged in OnCore within one business day to ensure timely review by the MHRI revenue cycle team for MedStar Health to maintain compliance with the Centers for Medicare and Medicaid Services (CMS) Clinical Trial Policy.

MHRI strives for efficient, compliant and transparent research billing by providing monthly metrics and encourages internal audits. In FY20, MedStar Health completed two internal research billing compliance audits which were favorable. In addition, Research Operations provides monthly metrics showing corrections made to a subject’s account before a bill is automatically sent to Medicare or a commercial payor. 

Thank you to the research coordinators and the Research Institute research revenue cycle team for all the hard work you put in daily! Know that it is recognized and greatly appreciated.

If you have any questions about research billing compliance or the process within OnCore, please contact [email protected].

MedStar Researchers Use Visualization Dashboards to Enhance Situation Awareness of COVID-19 Telehealth Initiatives

A collaborative team of researchers from across MedStar Health published a case report which examined the need for improved situation awareness of all telehealth operations to effectively monitor and proactively manage patient experience, healthcare provider experience, and platform performance.  The team included investigators from MedStar Health National Center for Human Factors in Healthcare, MedStar Health Research Institute, MedStar Simulation Training and Education Lab, MedStar Telehealth Innovation Center, and Georgetown University School of Medicine.

“Rapid Development of Visualization Dashboards to Enhance Situation Awareness of COVID-19 Telehealth Initiatives at a Multi-Hospital Healthcare System” was published in Journal of the American Medical Informatics Association.  The COVID-19 pandemic has required the need for prompt acceleration of telehealth programs to lessen community spread while providing safe patient care.  The researchers used a situation awareness model and five-step process to identify operational end-user needs, along with design and develop visualizations to meet those needs.  Three stakeholder groups (healthcare system executives, telehealth leaders, and telehealth managers) were identified and provided with visualization dashboards to seek their relative needs.

The multidisciplinary visualization team used a five-step process to support the launch and ongoing development of the telehealth program. The five steps were:

  • Subject Matter Expert Interviews to Increase Domain Knowledge
  • User Needs Analysis and Feature Identification
  • Processing Telehealth Data Sources
  • Visualization Design, Development, and Testing
  • Dissemination and Iterative Refinement

The results show that executive stakeholders needed weekly awareness of high-level metrics and trends to convey telehealth activity across the MedStar Health system. Telehealth leaders requested daily awareness of key operational indicators to monitor telehealth operations.  Telehealth managers and team members needed detailed information about their respective areas with the ability to diagnose where issues such as increased patient volumes, poor patient experiences, or dropped calls were occurring.

User feedback suggests the visualizations improved situational awareness and may have provided valuable information to better inform operational decisions. In the future, the researchers plan to improve data accessibility and gather more feedback from end-users for dashboard optimization.

The study team included Raj M. Ratwani, PhD; Ethan Booker, M.D; Ram A. Dixit, M.S; Stephen Hurst, Katharine T. Adams, Christian Boxley, Kristi Lysen-Hendershot, and Sonita S. Bennett, M.S.

Journal of the American Medical Informatics Association, DOI: 10.1093/jamia/ocaa161/5866982

July Peer-Reviewed Publications from MedStar Health

Congratulations to all MedStar researchers who had articles published in July 2020. The selected articles and link to PubMed provided below represent the body of work completed by MedStar Health investigators, physicians, and associates and published in peer-reviewed journals last month. The list is compiled from PubMed for any author using “MedStar” in the author affiliation.

Congratulations to this month’s authors! We look forward to seeing your future research.

View the full list of publications on here.

Selected research:

  1. Functional mitral regurgitation
    Current Opinion in Cardiology, 2020. DOI: 10.1097/HCO.0000000000000770
    Asch FM, Medvedofsky D.

  2. Infections in Burn Patients: Innovations in Infection Prevention and Treatment
    Surgical Infections, 2020. DOI: 1089/sur.2020.202
    Tejiram S, Shupp JW.

  3. Lymphoma survivors have an increased long-term risk of chronic kidney disease
    Leukemia & Lymphoma, 2020. DOI: 10.1080/10428194.2020.1786555
    Desai SH, Al-Shbool G, Desale S, Veis J, Malkovska V.

  4. Head Repositioning during Neurointerventional Procedures to Optimize Biplanar Imaging
    Journal of Neuroimaging, 2020. DOI: 1111/jon.12750
    Dowlati E, Zhou T, Stewart J, Felbaum DR, Liu AH, Mai JC, Armonda RA.

  5. Food Insecurity and Insulin Use in Hyperglycemic Patients Presenting to the Emergency Department
    Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 2020. DOI: 10.5811/westjem.2020.4.45918
    Nhoung HK, Goyal M, Cacciapuoti M, Day H, Hashemzadeh T, Magee M, Jarris YS.

Conflict of Interest Questionnaire for MedStar Health Researchers Joins with Georgetown

As of July 1, 2020, a single COI platform is available to all Researchers employed by MedStar Health (to include those located at MedStar Georgetown University Hospital (“MGUH”) or elsewhere on the Georgetown University campus). With the launch of a single COI platform for MedStar Health employed Researchers, the need for separate submissions through a MedStar Health platform and a Georgetown University platform will be eliminated. Both Georgetown University and MedStar Health have agreed to use the MedStar Health COI Platform for MedStar Health employed Researchers. The Questionnaire will be accessible to Researchers to submit disclosures throughout the entire fiscal year (July 1st – June 30th).

The COI-Smart platform will meet both organizations’ research COI reporting requirements. This new process will eliminate the Georgetown University COI disclosure for those Researchers who formerly completed a MedStar Health COI questionnaire and a Georgetown University questionnaire. MedStar Health and Georgetown University COI reviewers will have access to the information reported, will review transactions and implement a consolidated research management plan.

At the onset of a new study routing through MedStar Health/MedStar Health Research Institute or Georgetown University, in accordance with current practices, Researchers must update their COI questionnaire or verify that it is up-to-date. You will access the COI system in the same manner that you have in the past. If you held a research role at MedStar in fiscal year 2020 (FY20), you may have already entered data into the COISmart system during the fiscal year. If you have completed the questionnaire as a researcher during FY20, a link to the conflict of interest disclosure should have been sent to you.

MedStar Health policies require that all individuals engaged in the conduct of research complete the annual conflict of interest disclosure. The annual research conflicts of interest disclosure process is designed to manage financial and nonfinancial research interests. 

MGUH Researchers may contact Mary Schmiedel at [email protected] to establish a COI-Smart COI account. If you have any questions on the COI-Smart application, please contact Carol Mason at [email protected] or 410-772-6607 or Lauren Brummell at [email protected] or 410-772-6578.

MedStar Investigators Report on Myocardial Injury from COVID-19

MedStar Health researchers published a report highlighting two cases of COVID-19 infection with myocardial involvement with distinct mechanistic pathways and outcomes. The cases discussed the important decision strategies for these critically ill patients, such as the timing of cardiac catheterization (when indicated) and requirement of early hemodynamic support. “COVID-19 (SARS-Cov-2) and the heart – An ominous association” was published in Cardiovascular Revascularization Medicine.

Cardiovascular manifestations of COVID-19 can be diverse and complex, including myocardial injury, infarction, myocarditis simulating ST-segment elevation myocardial infarction, non-ischemic cardiomyopathy, coronary vasospasm, pericarditis, or stress(takotsubo) cardiomyopathy.  The publication discussed that based on the initial experience from Wuhan, China, that approximately 27.8% (52/187) of patients with COVID-19 exhibited myocardial injury. Myocardial injury was associated with worse out-comes of COVID-19, whereas the prognosis of patients with underlying cardiovascular disease but without myocardial injury was comparatively favorable.

The cases described in this report are patients with COVID-19 infection and myocardial involvement. The authors indicated that during the COVID-19 pandemic, management of patients with acute coronary syndrome and COVID-19 remains critically important.  Underlying cardiovascular disease and associated risk factors such as hypertension, coronary heart disease, and cardiomyopathy put patients at higher risk of developing myocardial injury during the course of their COVID-19 infection.

The team included Nauman Khalid, MD; Yuefeng Chen MD, PhD; Brian C. Case, MD; Evan Shlofmitz, DO; Jason P. Wermers, Toby Rogers, MD, PhD; Itsik Ben-Dor, MD; and Ron Waksman, MD.

Cardiovascular Revascularization Medicine, 2020, DOI: 10.1016/j.carrev.2020.05.009