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.

High-frequency response of subwavelength-structured metals in the petahertz domain.

Electromagnetic plane waves, incident on and reflecting from a dielectric-conductor interface, set up a standing wave in the dielectric with the B-field adjacent to the conductor. It is shown here how the harmonic time variation of this B-field induces an E-field and a conduction current J (c) within the skin depth of a real metal; and that at frequencies in the visible and near-infrared range, the imaginary term sigmai of the complex conductivity sigma = sigma(r) + isigma(i) dominates the optical response. Continuity conditions of the E-field through the surface together with the in-quadrature response of the conductivity determine the phase relation between the incident E-M field and J(c). If slits or grooves are milled into the metal surface, a displacement current in the dielectric gap and oscillating charge dipoles at the structure edges are established in quadrature phase with incident field. These dipoles radiate into the aperture and launch surface waves from the edges. They are the principle source of light transmission through the apertures.

Intern candidates who withdraw from contracts: incidence and internal medicine program directors' attitudes.

OBJECTIVE: To study the prevalence of intern candidates accepted through the National Resident Matching Program (NRMP) or after the match who subsequently withdraw and the attitudes of program directors regarding this issue. DESIGN: Mailed survey. SETTING: Four hundred fifty-four internal medicine program directors. MEASUREMENTS: Questionnaires assessing program directors' attitudes toward interns who contract for positions after having verbal or written agreements elsewhere (and the program directors who accept them), the importance of this problem, and the incidence of this problem. MAIN RESULTS: Fifty-five programs (of the 221 responding) experienced intern withdrawals. Programs with larger numbers of open positions after the match had more intern withdrawals (p = 0.03). Eleven of the program directors knew of the prior commitment of the intern, and in all cases the other program director was called for permission to accept the intern. Program directors had negative feelings about both the interns who withdrew and the program directors who accepted them. Community, municipal, and Veterans Affairs hospital program directors were significantly less negative than those in university and university-affiliated hospitals toward interns who withdrew from written commitments (p = 0.001) and the program directors who accepted them (p < 0.05). CONCLUSION: Problems with intern candidate withdrawals from offered/matched programs affect a significant proportion of programs, especially those with larger numbers of unmatched positions. Program directors are generally disapproving.

Beneficial effects of early hypocaloric enteral feeding on neonatal gastrointestinal function: preliminary report of a randomized trial.

In a prospective randomized trial, we studied the effects of early hypocaloric enteral feedings (PO) begun at 48 hours of age in 19 infants compared with 20 infants who received no enteral feedings (NPO) for at least the first 9 days of life. Both groups initially received the majority of their calories by parenteral alimentation. The groups were similar with respect to birth weight, gestational age, sex, Apgar score, and major neonatal diagnoses. The early enteral feeds proved to be significantly beneficial without an increased incidence of complications. The PO group reached full enteral feedings faster than the NPO group (31.2 vs 47.3 days). The PO group had a greater decline in serum bilirubin concentration over the first 2 weeks of life and spent less time under phototherapy (6.8 vs 9.5 days). Less cholestasis was observed among the PO infants (6.7% vs 33%), and peak direct bilirubin levels were also lower (0.7 vs 2.5 mg/dL). Osteopenia of prematurity, manifested by significantly lower alkaline phosphatase activity, was also decreased in the PO group, perhaps because of greater calcium intake during the first month among PO infants (1.3 vs 0.8 g). Compared with complete bowel rest, early onset of hypocaloric enteral feedings has beneficial effects on indirect hyperbilirubinemia, cholestatic jaundice, and metabolic bone disease of very low birth weight infants.

Pernicious anemia in Latin Americans is not a disease of the elderly.

Pernicious anemia is widely regarded as a disease of the elderly. However, it is expressed differently in black women, among the most striking differences being their younger age at presentation of the disease compared with whites. We now compared 92 Latin-American patients with 115 white and 100 black patients to see if similar age differences occur in other racial groups. Latin-American men and women were both significantly younger than white men and women, and were similar in age to blacks. Only 21% of Latin-American patients were 70 years of age or older, compared with 49% of whites. It is apparent that pernicious anemia is indeed predominantly a disease of the elderly in whites but that this is not the case in other racial groups.

Dermatoglyphic study of systemic lupus erythematosus.

Dermatoglyphic patterns were analyzed from two races of patients with SLE: a Mexican-American series of 27 females with SLE and 28 matched controls, and a Caucasian series of 28 females with SLE and 26 matched controls. Eighty-five measurements and 23 indices were analyzed. From these data, eleven parameters were statistically significant, four separating the Mexican-American SLE group from their controls and seven separating the Caucasian SLE group from their controls (P values less than 0.002 to less than 0.05). Only two parameters were significantly different between the two normal series, but nine parameters differentiated the Mexican-American SLE from the Caucasian SLE groups. A multiple linear discriminant function was computed using the most significant parameters. A misclassification rate of 25-30% was observed between patients and matched controls. Dermatoglyphic patterns have been shown to be genetically controlled. These data suggest a genetic abnormality associated with SLE.