Optimization of an EHR mobile application using the UFuRT conceptual framework.

Drchrono is an Electronic Healthcare Record (EHR) application designed specifically for the iPad. Described as portable, efficient and accessible anywhere, drchrono has several features that might be attractive to health care providers. However, EHRs have to conform to certain Federal Healthcare Information Technology Guidelines, which are evaluated in a series of 12 test procedures, defined by the Office of the National Coordinator for Health Information Technology (ONC). In this study, we evaluated Test Procedure for §170.302 (c) Maintain up-to-date problem list, in drchrono. The methodology for our evaluation was contained within Zhang's unified framework for usability, using UFuRT, i.e. user, functional, representation and task analyses. Based upon the analysis, using Adobe Flex, we then designed a prototype that corrected or improved on perceived weaknesses in the functionality served by the test procedure. We applied the test procedure taxonomy to a prototypic modification of drchrono, and then repeated the UFuRT usability analysis. We also used a 14-item heuristic evaluation by each member of our informatics team. Our findings support a conclusion that UFuRT is a valuable tool to evaluate EHR usability and that an "up-to-date problem" list may be customized, according to healthcare provider preference.

Comparison of the effectiveness of amitriptyline and gabapentin on chronic neuropathic pain in persons with spinal cord injury.

OBJECTIVE: To test the hypotheses that both amitriptyline and gabapentin are more effective in relieving neuropathic pain than an active placebo, diphenhydramine. DESIGN: Randomized, controlled, double blind, triple crossover 8-week trial. SETTING: Veterans Affairs medical center. PARTICIPANTS: Community dwelling adults with spinal cord injury (N=38) were recruited by telephone, letters, and flyers. INTERVENTION: Eight-week trial each of amitriptyline, gabapentin, and diphenhydramine. MAIN OUTCOME MEASURES: Pain intensity measured with a 10-cm visual analog scale (VAS) and an 11-point (0-10) numeric rating scale (NRS) and depressive symptomatology measured with the Center for Epidemiologic Studies Depression Scale-Short Form (CESD-SF). RESULTS: Baseline VAS scores for participants with low (< 10) CESD-SF scores was 4.61 and for those with high scores (> or = 10) it was 7.41. At week 8, in participants with high baseline CESD-SF scores, amitriptyline (mean, 4.21) was more effective than diphenhydramine (mean, 6.67; P=.035), and there was a nonsignificant trend suggesting that amitriptyline may be more effective than gabapentin (mean, 6.68; P=.061). Gabapentin was no more effective than diphenhydramine (P=.97). There was no significant difference among the medications for those with lower CESD-SF scores. Results could not be attributed to dropout rates, order or dose of medications, amount of medication taken for breakthrough pain, or side effects. CONCLUSIONS: Amitriptyline is more efficacious in relieving neuropathic pain than diphenhydramine at or below the level of spinal cord injury in people who have considerable depressive symptomatology.

Prediction of the effect of acute normovolemic hemodilution on the hematological constituents of sequestered autologous whole blood.

During acute normovolemic hemodilution (ANH), autologous whole blood is collected in a series of collection bags containing anticoagulant. The effect of hemodilution on the actual hematological constituents of this sequestered whole blood product has never been examined. We developed a mathematical model that predicts how whole blood bag constituents change during ANH to elucidate the theoretical basis for ANH efficacy. Formulas were derived to calculate the effect of ANH on [X], the blood constituent of interest. An exponential envelope was defined so that the projected impact of ANH on each constituent could be computed while initial blood volume and whole blood bag volume (WB(ANH)) were manipulated. Equivalency of autologous whole blood hemoglobin, platelets, and fibrinogen were determined by comparison with standard allogeneic blood products. We determined that the concentration of blood constituent X in a particular unit of collected blood ([X](n)) is provided as a fraction of the initial concentration ([X](0)). As WB(ANH) increases relative to estimated blood volume, the decrement in [X](n) increases in successive blood collection bags. Irrespective of initial blood volume, the equivalence of a 450-mL autologous whole blood bag to 1 U of packed red cells and 1 U of whole blood-derived platelet concentrate is 13.3 g/dL and 123 x 10(3)/microL, respectively. The impact of ANH on autologous whole blood constituents may be accurately predicted using this model. Conversion of WB(ANH) into equivalent allogeneic blood products could provide a useful method of comparing outcome in various ANH studies. The exponential envelope may be used to assess the actual ANH technique performed by the anesthesiologist, which in turn may impact quality assurance standards.

Prevalence and characteristics of chronic pain in veterans with spinal cord injury.

To assess prevalence and characteristics of individual chronic (>6 mo) pain components in the veteran spinal cord injury (SCI) population, we conducted a telephone survey with 348 (66%) of 530 veterans with SCI who received care from one regional Department of Veterans Affairs SCI center during a 3 yr period. The short-form McGill Pain Questionnaire was used to assess qualitative properties of the pain experience. Other questions were used to assess frequency, duration, intensity, exacerbating factors, and effects on daily activities. Of the participants, 75% reported at least one chronic pain component. The majority (83%) of the chronic pain components occurred daily (mean = 27.4 d/mo) and lasted most of the day (mean = 17.4 h/d). Mean pain intensity in the week before the interview averaged 6.7 (on a 0 to 10 scale), while worst pain intensity averaged 8.6. Two-thirds (67%) of the chronic pain components interfered with daily activities. The most commonly selected pain descriptors were "aching," "sharp," "hot-burning," and "tiring-exhausting." More research is needed to identify better ways to prevent, assess, and treat chronic pain in the veteran SCI population.

Impact of extracorporeal circuit prime volume reduction on whole blood sequestration during acute normovolemic hemodilution for adult cardiac surgery patients.

Acute normovolemic hemodilution (ANH) is a blood-conservation method in which whole blood (WB(ANH)) is sequestered into blood collection bags before the commencement of surgery. However, for cardiac surgery, extracorporeal circuit (ECC) priming techniques limit the amount of blood that may collected prior to the actual initiation of cardiopulmonary bypass (CPB). In this study, computational modeling was used to examine the effect of reducing extracorporeal "pump" prime volume (PPV) on WB(ANH) prior to the CPB. Increments of estimated blood volume (EBV), precardiopulmonary bypass hemoglobin concentration [Hb(Pre-CPB)], and PPV volume were manipulated to assess effects on predicted hemoglobin concentration during cardiopulmonary bypass [Hb(CPB)]. Similarly, increments of EBV and preanesthetic hemoglobin concentration [Hb(Pre-Anes)] were manipulated to examine the change in WB(ANH) volume. The impact of PPV reduction on the minimum acceptable precardiopulmonary bypass hemoglobin concentration [Hb(Pre-CPB-MA)] was then measured by computing PPV, EBV, and the minimum acceptable cardiopulmonary bypass hemoglobin [Hb(CPB-MA)]. Finally, by manipulating EBV and target hemoglobin concentration [Hb(Target)], the change in [Hb(Pre-CPB)] produced by PPV reduction was used to quantify the effect on WB(ANH) volume. The net increase in the [Hb(CPB)] produced by PPV reduction is inversely proportional to EBV. Higher [Hb(Pre-Anes)] or lower [Hb(Target)] facilitates sequestration of larger WB(ANH) volume. Although PPV and [Hb(Pre-CPB-MA)] bear a direct relationship, as EBV decreases, proportionally greater increases in [Hb(Pre-CPB-MA)] occur. The impact of PPV reduction on precardiopulmonary bypass hemoglobin concentration [Hb(Pre-CPB)] is reflected by the "excess hemoglobin" over the minimum hemoglobin threshold (designated as 7 g/dL in this study). For each 100-mL decrement in PPV, "excess hemoglobin" increases from 1% (EBV = 8000 mL) to 2% (EBV = 4000 mL). In turn, increases in "excess hemoglobin" are associated with expansion of WB(ANH) volume. In conclusion, sequential PPV reduction from 2000 mL increases the volume of WB(ANH) that potentially may be sequestered prior to initiation of CPB. Therefore, the combination of PPV reduction with ANH may represent a useful blood conservation approach in adult patients undergoing cardiac surgery with CPB.