Public Health and Epidemiology Informatics: Recent Research and Trends in the United States.

OBJECTIVES: To survey advances in public health and epidemiology informatics over the past three years. METHODS: We conducted a review of English-language research works conducted in the domain of public health informatics (PHI), and published in MEDLINE between January 2012 and December 2014, where information and communication technology (ICT) was a primary subject, or a main component of the study methodology. Selected articles were synthesized using a thematic analysis using the Essential Services of Public Health as a typology. RESULTS: Based on themes that emerged, we organized the advances into a model where applications that support the Essential Services are, in turn, supported by a socio-technical infrastructure that relies on government policies and ethical principles. That infrastructure, in turn, depends upon education and training of the public health workforce, development that creates novel or adapts existing infrastructure, and research that evaluates the success of the infrastructure. Finally, the persistence and growth of infrastructure depends on financial sustainability. CONCLUSIONS: Public health informatics is a field that is growing in breadth, depth, and complexity. Several Essential Services have benefited from informatics, notably, "Monitor Health," "Diagnose & Investigate," and "Evaluate." Yet many Essential Services still have not yet benefited from advances such as maturing electronic health record systems, interoperability amongst health information systems, analytics for population health management, use of social media among consumers, and educational certification in clinical informatics. There is much work to be done to further advance the science of PHI as well as its impact on public health practice.

Usability characteristics of self-administered computer-assisted interviewing in the emergency department: factors affecting ease of use, efficiency, and entry error.

OBJECTIVE: Self-administered computer-assisted interviewing (SACAI) gathers accurate information from patients and could facilitate Emergency Department (ED) diagnosis. As part of an ongoing research effort whose long-range goal is to develop automated medical interviewing for diagnostic decision support, we explored usability attributes of SACAI in the ED. METHODS: Cross-sectional study at two urban, academic EDs. Convenience sample recruited daily over six weeks. Adult, non-level I trauma patients were eligible. We collected data on ease of use (self-reported difficulty, researcher documented need for help), efficiency (mean time-per-click on a standardized interview segment), and error (self-report age mismatched with age derived from electronic health records) when using SACAI on three different instruments: Elo TouchSystems ESY15A2 (finger touch), Toshiba M200 (with digitizer pen), and Motion C5 (with digitizer pen). We calculated descriptive statistics and used regression analysis to evaluate the impact of patient and computer factors on time-per-click. RESULTS: 841 participants completed all SACAI questions. Few (<1%) thought using the touch computer to ascertain medical information was difficult. Most (86%) required no assistance. Participants needing help were older (54 ± 19 vs. 40 ± 15 years, p<0.001) and more often lacked internet at home (13.4% vs. 7.3%, p = 0.004). On multivariate analysis, female sex (p<0.001), White (p<0.001) and other (p = 0.05) race (vs. Black race), younger age (p<0.001), internet access at home (p<0.001), high school graduation (p = 0.04), and touch screen entry (vs. digitizer pen) (p = 0.01) were independent predictors of decreased time-per-click. Participant misclick errors were infrequent, but, in our sample, occurred only during interviews using a digitizer pen rather than a finger touch-screen interface (1.9% vs. 0%, p = 0.09). DISCUSSION: Our results support the facility of interactions between ED patients and SACAI. Demographic factors associated with need for assistance or slower interviews could serve as important triggers to offering human support for SACAI interviews during implementation. CONCLUSION: Understanding human-computer interactions in real-world clinical settings is essential to implementing automated interviewing as means to a larger long-term goal of enhancing clinical care, diagnostic accuracy, and patient safety.

Identifying appropriate recipients for CDC infectious risk donor kidneys.

Over 10% of deceased donors in 2011 met PHS/CDC criteria for infectious risk donor (IRD), and discard rates are significantly higher for kidneys from these donors. We hypothesized that patient phenotypes exist for whom the survival benefit outweighs the infectious risk associated with IRDs. A patient-oriented Markov decision process model was developed and validated, based on SRTR data and meta-analyses of window period risks among persons with IRD behaviors. The Markov model allows patients to see, for their phenotype, their estimated survival after accepting versus declining an IRD offer, graphed over a 5-year horizon. Estimated 5-year survival differences associated with accepting IRDs ranged from -6.4% to +67.3% for a variety of patient phenotypes. Factors most predictive of the survival difference with IRD transplantation were age, PRA, previous transplant, and the expected time until the next non-IRD deceased donor offer. This study suggests that survival benefit derived from IRD kidneys varies widely by patient phenotype. Furthermore, within the inherent limitations of model-based prediction, this study demonstrates that it is possible to identify those predicted to benefit from IRD kidneys, and illustrates how estimated survival curves based on a clinical decision can be presented to better inform patient and provider decision-making.

Health services research evaluation principles. Broadening a general framework for evaluating health information technology.

BACKGROUND: Our forthcoming national experiment in increased health information technology (HIT) adoption funded by the American Recovery and Reinvestment Act of 2009 will require a comprehensive approach to evaluating HIT. The quality of evaluation studies of HIT to date reveals a need for broader evaluation frameworks that limits the generalizability of findings and the depth of lessons learned. OBJECTIVE: Develop an informatics evaluation framework for health information technology (HIT) integrating components of health services research (HSR) evaluation and informatics evaluation to address identified shortcomings in available HIT evaluation frameworks. METHOD: A systematic literature review updated and expanded the exhaustive review by Ammenwerth and deKeizer (AdK). From retained studies, criteria were elicited and organized into classes within a framework. The resulting Health Information Technology Research-based Evaluation Framework (HITREF) was used to guide clinician satisfaction survey construction, multi-dimensional analysis of data, and interpretation of findings in an evaluation of a vanguard community health care EHR. RESULTS: The updated review identified 128 electronic health record (EHR) evaluation studies and seven evaluation criteria not in AdK: EHR Selection/Development/Training; Patient Privacy Concerns; Unintended Consequences/ Benefits; Functionality; Patient Satisfaction with EHR; Barriers/Facilitators to Adoption; and Patient Satisfaction with Care. HITREF was used productively and was a complete evaluation framework which included all themes that emerged. CONCLUSIONS: We can recommend to future EHR evaluators that they consider adding a complete, research-based HIT evaluation framework, such as HITREF, to their evaluation tools suite to monitor HIT challenges as the federal government strives to increase HIT adoption.

Advice for Decision Makers Based on an Electronic Health Record Evaluation at a Program for All-inclusive Care for Elders Site.

OBJECTIVE: Provide evidence-based advise to "Program of All-inclusive Care for the Elderly" (PACE) decision makers considering implementing an electronic health record (EHR) system, drawing on the results of a mixed methods study to examine: (1) the diffusion of an EHR among clinicians documenting direct patient care in a PACE day care site, (2) the impact of the use of the EHR on the satisfaction levels of clinicians, and (3) the impact of the use of the EHR on patient functional outcomes. METHODS: Embedded mixed methods design with a post-test design quantitative experiment and concurrent qualitative component. Quantitative methods included: (1) the EHR audit log used to determine the frequency and timing during the week of clinicians' usage of the system; (2) a 22-item clinician satisfaction survey; and (3) a 16-item patient functional outcome questionnaire related to locomotion, mobility, personal hygiene, dressing, feeding as well the use of adaptive devices. Qualitative methods included observations and open-ended, semi-structured follow-up interviews. Qualitative data was merged with the quantitative data by comparing the findings along themes. The setting was a PACE utilizing an EHR in Philadelphia: PACE manages the care of nursing-home eligible members to enable them to avoid nursing home admission and reside in their homes. Participants were 39 clinicians on the multi-disciplinary teams caring for the elders and 338 PACE members. RESULTS: Clinicians did not use the system as intended, which may help to explain why the benefits related to clinical processes and patient outcomes as expected for an EHR were not reflected in the results. Clinicians were satisfied with the EHR, although there was a non-significant decline between 11 and 17 months post implementation of the EHR. There was no significant difference in patient functional outcome the two time periods. However, the sample size of 48 was too small to allow any conclusive statements to be made. Interpretation of findings underscores the importance of the interaction of workflow and EHR functionality and usability to impact clinician satisfaction, efficiency, and clinician use of the EHR. CONCLUSION: This research provides insights into EHR use in the care of the older people in community-based health care settings. This study assessed the adoption of an EHR outside the acute hospital setting and in the community setting to provide evidence-based recommendations to PACE decision makers considering implementing an EHR.

New concepts in systemic autoimmunity testing.

Diagnosis of systemic autoimmune diseases is highly complex, and it is becoming increasingly difficult to make assumptions about the functional roles and diagnostic significance of autoantibodies. The latter is mainly due to the fact that results from different assay systems are not interchangeable. A laboratory "gold standard" which helps the clinician to differentiate irrelevant autoimmune phenomena from significant autoimmune diseases at an early stage, is clearly missed. To meet this challenge, a rheuma entrance screening (RES) assay toolbox is proposed based on fully-automated enzyme immunoassay (EIA) technology on one system for the clinical and routine laboratory. The RES concept is intended to cover the most important syndromes of systemic rheumatic diseases, i.e. collagenosis, early rheumatoid arthritis, early osteoarthritis, anti-phospholipid syndrome and inflammation. The serological part of diagnosis of these diseases comprises testing for anti-nuclear antibodies (ANA), rheumatoid factor (RF), low levels of C-reactive protein (CRP), and disease-specific anti-phospholipid antibodies, e.g. anti-beta-2 glycoprotein I (anti-beta2 GPI). To eliminate the known problems of varying assay systems in this field, a novel, objective, rapid and reproducible approach to screen for such analytes in patient serum or plasma more efficiently is the application of EIAs on the fully-automated immunoassay analyser COBAS CORE (Roche Diagnostics GmbH, Mannheim, Germany). The combined use of the RES (COBAS CORE HEp2 ANA EIA, COBAS CORE RF EIA Quant, COBAS CORE CRP EIA Quant and COBAS CORE Anti-beta2 GPI EIA) is intended for patients sent to the laboratory with the primary suspicion of harbouring a systemic rheumatic disease.

Communication and information technology in medical education.

The past few years have seen rapid advances in communication and information technology (C&IT), and the pervasion of the worldwide web into everyday life has important implications for education. Most medical schools provide extensive computer networks for their students, and these are increasingly becoming a central component of the learning and teaching environment. Such advances bring new opportunities and challenges to medical education, and are having an impact on the way that we teach and on the way that students learn, and on the very design and delivery of the curriculum. The plethora of information available on the web is overwhelming, and both students and staff need to be taught how to manage it effectively. Medical schools must develop clear strategies to address the issues raised by these technologies. We describe how medical schools are rising to this challenge, look at some of the ways in which communication and information technology can be used to enhance the learning and teaching environment, and discuss the potential impact of future developments on medical education.

HEp2 ANA EIA: a new fully automated assay for the screening of antinuclear antibodies.

BACKGROUND: Screening for antinuclear antibodies is performed for various systemic autoimmune diseases with various different techniques. A more recent approach to ANA screening is the use of enzyme immunoassays. OBJECTIVES: To introduce the new COBAS CORE HEp2 ANA EIA, the first fully automated enzyme immunoassay for the detection of ANA in serum and plasma of patients with suspected systemic autoimmune disease. METHODS: A method comparison between the new HEp2 ANA EIA and immunofluorescence assays on HEp2 cells was performed in two groups--977 patients with systemic autoimmune disorders and 952 healthy subjects with no autoimmune disease-related diagnosis. RESULTS: The clinical sensitivity in the patient group was 79.8% for HEp2 ANA EIA and 89.5% for IFA, and the clinical specificity in the control group was 91.7% for HEp2 ANA EIA and 93.9% for IFA. The analysis of 830 routine samples showed an overall good concordance of 85% between both assays. Further examination of the discrepant results showed 8% discrepant negative results for the HEp2 ANA EIA assay compared to 21% for IFA. Discrepant positive results were found in 37.9% and 33% of samples for the HEp2 ANA EIA and the IFA, respectively. CONCLUSION: The HEp2 ANA EIA is the first fully automated assay for the detection of ANA in serum and plasma. The assay shows improved sensitivity in ANA determination and a similar performance, compared to the standard method of IFA.

Bayesian communication: a clinically significant paradigm for electronic publication.

OBJECTIVE: To develop a model for Bayesian communication to enable readers to make reported data more relevant by including their prior knowledge and values. BACKGROUND: To change their practice, clinicians need good evidence, yet they also need to make new technology applicable to their local knowledge and circumstances. Availability of the Web has the potential for greatly affecting the scientific communication process between research and clinician. Going beyond format changes and hyperlinking, Bayesian communication enables readers to make reported data more relevant by including their prior knowledge and values. This paper addresses the needs and implications for Bayesian communication. FORMULATION: Literature review and development of specifications from readers', authors', publishers', and computers' perspectives consistent with formal requirements for Bayesian reasoning. RESULTS: Seventeen specifications were developed, which included eight for readers (express prior knowledge, view effect size and variability, express threshold, make inferences, view explanation, evaluate study and statistical quality, synthesize multiple studies, and view prior beliefs of the community), three for authors (protect the author's investment, publish enough information, make authoring easy), three for publishers (limit liability, scale up, and establish a business model), and two for computers (incorporate into reading process, use familiar interface metaphors). A sample client-only prototype is available at http://omie.med.jhmi.edu/bayes. CONCLUSION: Bayesian communication has formal justification consistent with the needs of readers and can best be implemented in an online environment. Much research must be done to establish whether the formalism and the reality of readers' needs can meet.

Developmental dysplasia of the hip practice guideline: technical report. Committee on Quality Improvement, and Subcommittee on Developmental Dysplasia of the Hip.

OBJECTIVE: To create a recommendation for pediatricians and other primary care providers about their role as screeners for detecting developmental dysplasia of the hip (DDH) in children. PATIENTS: Theoretical cohorts of newborns. METHOD: Model-based approach using decision analysis as the foundation. Components of the approach include the following: PERSPECTIVE: Primary care provider. OUTCOMES: DDH, avascular necrosis of the hip (AVN). OPTIONS: Newborn screening by pediatric examination; orthopaedic examination; ultrasonographic examination; orthopaedic or ultrasonographic examination by risk factors. Intercurrent health supervision-based screening. PREFERENCES: 0 for bad outcomes, 1 for best outcomes. MODEL: Influence diagram assessed by the Subcommittee and by the methodology team, with critical feedback from the Subcommittee. EVIDENCE SOURCES: Medline and EMBASE search of the research literature through June 1996. Hand search of sentinel journals from June 1996 through March 1997. Ancestor search of accepted articles. EVIDENCE QUALITY: Assessed on a custom subjective scale, based primarily on the fit of the evidence to the decision model. RESULTS: After discussion, explicit modeling, and critique, an influence diagram of 31 nodes was created. The computer-based and the hand literature searches found 534 articles, 101 of which were reviewed by 2 or more readers. Ancestor searches of these yielded a further 17 articles for evidence abstraction. Articles came from around the globe, although primarily Europe, British Isles, Scandinavia, and their descendants. There were 5 controlled trials, each with a sample size less than 40. The remainder were case series. Evidence was available for 17 of the desired 30 probabilities. Evidence quality ranged primarily between one third and two thirds of the maximum attainable score (median: 10-21; interquartile range: 8-14). Based on the raw evidence and Bayesian hierarchical meta-analyses, our estimate for the incidence of DDH revealed by physical examination performed by pediatricians is 8.6 per 1000; for orthopaedic screening, 11.5; for ultrasonography, 25. The odds ratio for DDH, given breech delivery, is 5.5; for female sex, 4.1; for positive family history, 1.7, although this last factor is not statistically significant. Postneonatal cases of DDH were divided into mid-term (younger than 6 months of age) and late-term (older than 6 months of age). Our estimates for the mid-term rate for screening by pediatricians is 0.34/1000 children screened; for orthopaedists, 0.1; and for ultrasonography, 0.28. Our estimates for late-term DDH rates are 0.21/1000 newborns screened by pediatricians; 0.08, by orthopaedists; and 0.2 for ultrasonography. The rates of AVN for children referred before 6 months of age is estimated at 2.5/1000 infants referred. For those referred after 6 months of age, our estimate is 109/1000 referred infants. The decision model (reduced, based on available evidence) suggests that orthopaedic screening is optimal, but because orthopaedists in the published studies and in practice would differ, the supply of orthopaedists is relatively limited, and the difference between orthopaedists and pediatricians is statistically insignificant, we conclude that pediatric screening is to be recommended. The place of ultrasonography in the screening process remains to be defined because there are too few data about postneonatal diagnosis by ultrasonographic screening to permit definitive recommendations. These data could be used by others to refine the conclusions based on costs, parental preferences, or physician style. Areas for research are well defined by our model-based approach.

Reducing the paper load: computer-based patient records.

Physicians burdened with increasing paper work may find relief in computer-based patient records (CPR). CPRs may aid clinicians in the areas of billing, documentation, reporting, and data retrieval. Value-added features like decision support and event monitoring facilitate patient outcome, decrease health care costs and allow improved administration. The authors discuss obstacles in the use of computers in patient care with a focus on security, confidentiality, and Y2K.

Restricted natural language processing for case simulation tools.

For Interactive Patient II, a multimedia case simulation designed to improve history-taking skills, we created a new natural language interface called GRASP (General Recognition and Analysis of Sentences and Phrases) that allows students to interact with the program at a higher level of realism. Requirements included the ability to handle ambiguous word senses and to match user questions/queries to unique Canonical Phrases, which are used to identify case findings in our knowledge database. In a simulation of fifty user queries, some of which contained ambiguous words, this tool was 96% accurate in identifying concepts.

Patient preferences for early discharge after laparoscopic cholecystectomy.

UNLABELLED: Patients may have concerns about their ability to manage postoperative symptoms at home after ambulatory surgery. We assessed patients' attitudes toward postoperative care at home or in the hospital after laparoscopic cholecystectomy. Thirty-eight patients undergoing elective laparoscopic cholecystectomy were pre- and postoperatively (within a week each) presented with scenarios describing symptoms of differing severity in either a home or hospital setting and were asked to rank and rate the relative desirability of the scenarios using rating scale, standard gamble, and willingness-to-pay techniques. Preoperatively, 16 (42%), 21 (55%), and 30 (79%) patients ranked pain of mild, moderate, and severe levels, respectively, as worse than the respective levels of nausea and vomiting. Of 24 patients, 19 (79%) preferred home care to hospital care for mild symptoms, and 12 of 22 patients (55%) preferred home care to hospital care for moderate symptoms. The average ratings were 20, 53, and 90 for mild, moderate, and severe symptoms, respectively, where 0 = no symptoms and 100 = the worst symptoms possible. Patients who preferred care outside the home indicated that they were willing to pay a mean of $142 (maximum $410) as a maximal copayment to have postoperative care in the hospital and a mean of $255 to receive care in a medical hotel-like facility. Postoperative assessment correlated highly with the preoperative assessment (correlation coefficient >0.6 for rating, standard gamble, and willingness-to-pay assessments). We conclude that patients vary in their attitudes toward where they would like to receive postoperative care. Attitudes assessed preoperatively may predict their attitudes postoperatively. IMPLICATIONS: Patients preferred to be at home for mild postoperative symptoms but in the hospital for worse postoperative symptoms. Preferences did not change with different methods of asking and were the same pre- and postoperatively. If patients made choices for their care before their procedure, they would still be happy with those decisions postoperatively.

An ethnographic, controlled study of the use of a computer-based histology atlas during a laboratory course.

OBJECTIVE: To evaluate the use and effect of a computer-based histology atlas during required laboratory sessions in a medical school histology course. DESIGN: Ethnographic observation of students' interactions in a factorial, controlled setting. MEASUREMENTS: Ethnographer's observations; student and instructor self-report survey after each laboratory session with items rated from 1 (least) to 7 (best); microscope practicum scores at the end of the course. RESULTS: Between groups assigned the atlas and those not, the ethnographer found qualitative differences in the semantic categories used by students in communicating with each other and with the faculty. Differences were also found in the quality of the interactions and in the learning styles used with and without the computer present in the laboratory. The most interactive learning style was achieved when a pair of students shared a computer and a microscope. Practicum grades did not change with respect to historical controls. Students assigned the atlas, compared with those not assigned, reported higher overall satisfaction (a difference in score of 0.1, P = 0.003) and perceived their fellow students to be more helpful (a difference of 0.11, P = 0.035). They rated the usefulness of the microscope lower (a difference of 0.23, P<0.001). CONCLUSION: A computer-based histology atlas induces qualitative changes in the histology laboratory environment. Most students and faculty reacted positively. The authors did not measure the impact on learning, but they found that there are aspects of using the atlas that instructors must manipulate to make learning optimal. Ethnographic techniques can be helpful in delineating the context and defining what the interventions might be.

Delivering labeled teaching images over the Web.

The Web provides educators with the best opportunity to date for distributing teaching images across the educational enterprise and within the clinical environment. Experience in the pre-Web era showed that labels and information linked to parts of the image are crucial to student learning. Standard Web technology does not enable the delivery of labeled images. We have developed an environment called OverLayer that succeeds in the authoring and delivering of such images in a variety of formats. OverLayer has a number of functional specifications, based on the literature and on our experience, among them, the following: Users should be able to find components by name or by image; to receive feedback about their choice to test themselves. The image should be of arbitrary size; should be reusable; should be linked to further information; should be stand-alone files. The labels should not obscure the image; should be linked to further information. Images should be stand-alone files that can be transferred among faculty members. Implemented in Java, OverLayer (http:/(/)omie.med.jhmi.edu/overlayer) has at its heart a set of object classes that have been reused in a number of applets for different teaching purposes and a file format for creating OverLayer images. We have created a 350-image histology library and a 500-image pathology library, and are working on a 400-image GI endoscopy library. We hope that the OverLayer suite of classes and implementations will help to further the gains made by previous image-based hyperlinked technologies.

Certification standards transfer: from committee to laboratory.

The ISO 9000 Standards series were developed to provide the international manufacturing industry with a framework to ensure purchased products meet quality criteria. Section 4 of ISO 9001, Quality System Model for Quality Assurance in Design, Development, Production, Installation and Servicing, contains 20 aspects of a quality system that must be addressed by an organization in order to receive ISO 9001 certification. This concept is extended to the clinical laboratory, where a quality system program establishes for the customer (patient/clinician) that the purchased product (requested information on a submitted specimen-test result) meets established quality norms. In order to satisfy the customer, the providing organization must have policies and procedures in place that ensure a quality product, and be certified. To become certified the organization must, through an inspection process, demonstrate to an independent accrediting agency that it meets defined standards. In the United States, the government through the Clinical Laboratory Improvement Amendment (CLIA) 1988 established quality standards for the clinical laboratory. The College of American Pathologists (CAP), through its Laboratory Accreditation Program (LAP), serves as an independent agency that certifies that laboratories meet standards. To demonstrate the applicability of an established clinical laboratory accreditation program to ISO 9001 certification, the standards and checklists of CLIA 1988 and the CAP LAP will be examined to determine their conformance to ISO 9001, Section 4.