Integrating public health applications with commercial EMRs.

At HIMSS 2007, we demonstrated how three processes of public health agencies could be facilitated through use of a prototype health information exchange, satisfying the AHIC biosurveillance use case.

Communicable disease case entry using PDAs and public wireless networks.

Concerns about detecting and responding to attacks with biowarfare agents have resulted in the development of deployable case reporting systems, e.g. RSVP. We implement a proof of concept web-based information system to be used securely from personal digital assistants over public wireless networks, by public health field workers for routine and emergent case reporting. The system collects data for a local health jurisdiction, provides content- and event-based notification, and forwards case reports to the Colorado State communicable disease reporting system (CEDRS). We believe this demonstrates a useful integration of portable and web-based technologies with public health practice.

National Pharmaceutical Stockpile drill analysis using XML data collection on wireless Java phones.

This study describes an informatics effort to track subjects through a National Pharmaceutical Stockpile (NPS) distribution drill. The drill took place in Seattle on 1/24/2002. Washington and the State Department of Health are among the first in the nation to stage a NPS drill testing the distribution of medications to mock patients, thereby testing the treatment capacity of the plan given a post-anthrax exposure scenario. The goal of the Public Health Informatics Group at the University of Washington (www.phig.washington.edu) was to use informatics approaches to monitor subject numbers and elapsed time. This study compares accuracy of time measurements using a mobile phone Java application to traditional paper recording in a live drill of the NPS. Pearson correlation = 1.0 in 2 of 3 stations. Differences in last station measurements can be explained by delay in recording of the exit time. We discuss development of the application itself and lessons learned. (MeSH Bioterrorism, Informatics, Public Health)

Informatics for Peru in the new millennium.

INTRODUCTION: As efforts continue to narrow the digital divide between the North and South, a new biomedical and health informatics training effort has been launched in Peru. This report describes the first year of work on this collaborative effort between the University of Washington (Seattle) Universidad Peruana Cayetano Heredia and Universidad Nacional de San Marcos (Peru) OBJECTIVES: To describe activities in the first year of a new International Research and Training Program in Biomedical and Health Informatics. METHODS: Descriptive analysis of key activities including an assessment of electronic environment through observation and survey, an in country short course with quantitative evaluation, and first round of recruitment of Peruvian scholars for long-term training in Seattle. RESULTS: A two-week short course on informatics was held in the country. Participants' success in learning was demonstrated through pretest/posttest. A systematic assessment of electronic environment in Peru was carried out and two scholars for long-term training were enrolled at the University of Washington, Seattle. DISCUSSION: Initial activity in the collaborative training effort has been high. Of particular importance in this environment is orchestration of efforts among interested parties with similar goals in Peru, and integration of informatics skills into ongoing large-scale research projects in country.

A preliminary evaluation of guideline content mark-up using GEM--an XML guideline elements model.

OBJECTIVE: To describe application of GEM to analysis and categorization of guideline content. METHOD: We examined the application of GEM constructs to the AAP guideline on neurodiagnostic evaluation of febrile seizures. Subjects at 4 sites marked-up the guideline content using a hierarchical template that includes branches for identity, developer, purpose, intended audience, method of development, knowledge components, testing, and review. The types of elements used were tabulated. Subjects were surveyed regarding the usability of the model. RESULTS: Eight subjects analyzed the guideline, using between 46 and 149 elements to model its content. There was considerable variation in the application of elements. The number of elements used correlated with time to complete the task. Subjects found application of GEM to be straightforward in 6 of 8 categories and sufficiently comprehensive to model the guideline's information content. CONCLUSIONS: Subjects found GEM constructs were able to model the content of the guideline. Improved editing tools will facilitate translation.

Reengineering a database for clinical trials management: lessons for system architects.

This paper describes the process of enhancing Trial/DB, a database system for clinical studies management. The system's enhancements have been driven by the need to maximize the effectiveness of developer personnel in supporting numerous and diverse users, of study designers in setting up new studies, and of administrators in managing ongoing studies. Trial/DB was originally designed to work over a local area network within a single institution, and basic architectural changes were necessary to make it work over the Internet efficiently as well as securely. Further, as its use spread to diverse communities of users, changes were made to let the processes of study design and project management adapt to the working styles of the principal investigators and administrators for each study. The lessons learned in the process should prove instructive for system architects as well as managers of electronic patient record systems.

GEM: a proposal for a more comprehensive guideline document model using XML.

OBJECTIVE: To develop a guideline document model that includes a sufficiently broad set of concepts to be useful throughout the guideline life cycle. DESIGN: Current guideline document models are limited in that they reflect the specific orientation of the stakeholder who created them; thus, developers and disseminators often provide few constructs for conceptualizing recommendations, while implementers de-emphasize concepts related to establishing guideline validity. The authors developed the Guideline Elements Model (GEM) using XML to better represent the heterogeneous knowledge contained in practice guidelines. Core constructs were derived from the Institute of Medicine's Guideline Appraisal Instrument, the National Guideline Clearinghouse, and the augmented decision table guideline representation. These were supplemented by additional concepts from a literature review. RESULTS: The GEM hierarchy includes more than 100 elements. Major concepts relate to a guideline's identity, developer, purpose, intended audience, method of development, target population, knowledge components, testing, and review plan. Knowledge components in guideline documents include recommendations (which in turn comprise conditionals and imperatives), definitions, and algorithms. CONCLUSION: GEM is more comprehensive than existing models and is expressively adequate to represent the heterogeneous information contained in guidelines. Use of XML contributes to a flexible, comprehensible, shareable, and reusable knowledge representation that is both readable by human beings and processible by computers.

Hamstrings--an anterior cruciate ligament protagonist. An in vitro study.

A cadaveric model that incorporated quadriceps and hamstrings muscle loads was developed to simulate the squat exercise. The addition of hamstrings load affected knee kinematics in two ways. First, anterior tibial translation during flexion ("femoral roll-back") was significantly reduced (P = 0.003) and second, internal tibial rotation during flexion was reduced (P = 0.008). However, quadriceps force was unaffected by the addition of hamstrings load. Thus, it seems likely that hamstrings muscle activity that has been observed in vivo during a squat probably functions synergistically with the anterior cruciate ligament to provide anterior knee stability. After the ACL was sectioned, anterior tibial translation was significantly increased during the squat (P = 0.04). The anterior cruciate ligament was then reconstructed using a graft instrumented with a load cell. During passive motion, maximal graft tension was at full extension. During simulated squat exercise, the addition of hamstrings caused a significant decrease in graft load (P = 0.006). During the squat, maximal graft tension was at full extension, and was equal to the graft tension at full passive extension. Thus, the squat exercise may be useful in the early stages of anterior cruciate ligament rehabilitation.