Restructuring the electronic medical record to incorporate full digital signature capability.

The security of Electronic Medical Records can be enhanced by the addition of digital signatures that guarantee data integrity, authenticate the signer, and establish non-repudiation through the use of public key encryption. The task is complicated by the contribution of multiple providers to an encounter and the entry of data at multiple points in time Dividing encounters into an episode of care and redesigning the data model of the EMR will facilitate full signature capabilities. Generation of digital signatures is best accomplished using microprocessors on smart cards that control visibility of the private keys and assist in user authentication. The Java Programming Language including cryptography extensions and a smart card API is a useful tool for adding digital signature to an EMR. Inter-operability of signatures and continuity of signature will require attention to standards and preservation of cryptography and authentication certificate archives. Digital signatures will need to accommodate changes in data storage formats when information is transported between EMR systems using XML or other transaction standards because the original signatures will not validate if the data storage format changes. The costs of adding digital signature to EMR mandates serious examination of the business case for digital signature within an EMR as compared with transactions such as electronic prescriptions. At present, there is no regulatory requirement for digital signature of an EMR.

Correlations of cardiovascular disease risk factors between African American siblings.

OBJECTIVES: This study examines intrasibling correlations at 2 points during childhood for African American siblings with the same father, different fathers, a father present in the home, and no father present in the home. STUDY DESIGN: Cardiovascular disease (CVD) risk factors were assessed in 267 pairs of African American siblings (visit 1) and in 79 of these siblings approximately 28 months later (visit 2). RESULTS: As a group, correlations of CVD risk factors between African American siblings with the same father were greater than those for African American siblings with different fathers in visit 1 (P <.05). However, having a father present in the home was associated with significantly lower intrasibling correlations for girth and total cholesterol in visit 2 (P <.005). Intrasibling correlations for the 4 family subgroups suggest that CVD risk factors were most similar in siblings who shared the same father but who had no father present in the home. CONCLUSIONS: Intrasibling correlations for African American children were influenced by whether they shared the same father and whether a father was present in their home, reflecting both genetic and environmental influences. Family composition should be considered when family CVD risk factors are used to predict CVD risk in children.

Intrafamilial relations of cardiovascular disease risk factors in African-Americans: longitudinal results from DC SCAN.

BACKGROUND: Few studies have examined intrafamilial patterns of cardiovascular disease (CVD) risk factors in African-American families or identified potential influences on these patterns. This study examines the effects of age and sex of child on correlations between siblings during childhood as well as between mothers and their offspring in African-American families at two points in time. METHODS: CVD risk factors were assessed in a sample of 267 pairs of African-American siblings and their mothers. One hundred nine of these families were selected for a second assessment of CVD risk factors approximately 28 months later. RESULTS: Older siblings had significantly greater correlations than younger siblings with mothers' low-density lipoproteins (r = 0.61 versus r = 0.43 for older and younger siblings, respectively), apolipoprotein A-I (r = 0. 46 versus r = 0.16), and lipoprotein (a) (r = 0.71 versus r = 0.34). Correlations between female siblings were significantly higher than between male siblings for total cholesterol (r = 0.74 versus r = 0. 18 for female versus male siblings), triglycerides (r = 0.56 versus r = 0.05), and apolipoprotein B (r = 0.72 versus r = 0.31); they were also higher between female siblings than between mixed-sex siblings for measures of adiposity (r = 0.46 versus r = 0.19) and total cholesterol (r = 0.74 versus r = 0.27). CONCLUSIONS: Significant intrafamilial correlations for African-American children were influenced by both age and sex of siblings, reflecting potential genetic and environmental influences. Assessing family patterns of CVD risk factors in high-risk populations may assist in the early identification of children who can benefit most from intervention.

Using the Java language to develop computer based patient records for use on the Internet.

The development of the Java Programming Language by Sun Microsystems has provided a new tool for the development of Internet based applications. Our preliminary work has shown how Java can be used to program an Internet based CBPR. Java is well suited to the needs of patient records and can interface with clinical data repositories written in MUMPS or SQL.

Comparison of dietary intake methods with young children.

To select a valid method for obtaining dietary intake of preschool children, food intake of 17 children (8 in daycare programs and 9 in home care) was measured for three days. Each day, home caregivers and daycare staff were asked to recall what the child had eaten during the previous 24 hours. After the third day, the Willett Food Frequency Questionnaire was administered to assess intake during the preceding seven days, which included the three days of measured foods. There were no significant differences between means from measured and recalled intake. Although the children's gender and care status (daycare versus home care) made no difference in measured intake, there were significant differences in recalled intake for energy and percent of calories from saturated fat. In this study the questionnaire did not provide an accurate assessment of measured intake and could not replace the dietary recall.

A new home health classification method.

The Home Health Care Classification Method used with the assessment instrument and scoring methodology can predict resource requirements in terms of three cohorts of time and volume of nursing and all provider visits. This HHCC Method can be used to predict care requirements for planning purposes, including the staffing and provider mix, to determine the scope and type of services, to identify the fiscal needs and constraints, and to fulfill other administrative needs. It also can track the home care process, measure patient outcomes for home care quality assurance, facilitate efficient documentation, and form the basis for predicting costs of home health care. The coding schemes developed for the Classification of Home Health Care Nursing Diagnoses and Interventions can be used not only to code but also statistically to analyze home care nursing data. This classification provides the mechanism to link nursing diagnoses to nursing interventions. It can be used in other research studies and has the potential for the design of computer systems for home health care.

Relationships among black families' cardiovascular disease risk factors.

BACKGROUND: As participants in the District of Columbia Studies of Children's Activity and Nutrition (D.C. SCAN), 262 black mothers and two of each mother's children (3-4 and 8-10 years of age) were measured in their homes for selected cardiovascular disease risk factors: serum total cholesterol, systolic and diastolic blood pressures, height and weight for body mass index, fitness (sum of pulses), activity, and triceps and subscapular skinfolds. RESULTS: For each measure, mothers in the highest quartile were more likely to have children who were also in the highest quartile, and mothers in the lowest quartile were more likely to have children who were in the lowest quartile. For the physiological measures, (with the exception of systolic blood pressure), correlations tended to be stronger between the siblings than between the younger child and the mother, and older siblings' physiological measures contributed to the prediction of younger siblings' physiological measures after controlling for mothers' physiological measures. Relationships between family cardiovascular disease risk factor history and children's serum total cholesterol, and systolic and diastolic blood pressure levels tended to be gender related; i.e., family cardiovascular disease risk factors on the mother's side were more likely to be related to levels among the female but not the male children and vice versa. When personal characteristics were controlled for, the family's cardiovascular disease history was related more strongly to the younger than to the older sibling's systolic and diastolic blood pressure levels. CONCLUSIONS: Results tend to substantiate the importance of screening and counseling other family members, especially a child of the same gender as the parent with a cardiovascular disease or an elevated risk factor level.

A Nursing Intervention Taxonomy for home health care.

One way to develop nursing theory is to extract it from what is actually being done by nurses in practice. Saba et al. provide this service for home health nursing services. Not only does their taxonomy help define the field, but it also develops a structure for care reimbursement.

You Can Control Asthma: evaluation of an asthma education program for hospitalized inner-city children.

A self-management education program was designed for staff nurses to offer children while they received medical care for asthma in the hospital. The program uses videotapes, written activity books and nurse discussion with the patient. Evaluation was conducted to assess program feasibility and impact. Pre- and post-tests of 40 children age 6-12 years revealed that the children had statistically significant increases in knowledge of and expected response to early warning signs of acute asthma, and in their sense of personal control (Health Locus of Control). Parents reported an increased use of asthma self-management techniques for acute episodes of asthma. Medical record review for a 15 month pre- and post-period indicated reductions in emergency room use. Inpatient hospital based education offers a critical opportunity to introduce asthma management skills, especially to children not reached by more traditional programs.

A process evaluation of the District of Columbia "Know Your Body" project.

A process evaluation was conducted of the effectiveness of the "Know Your Body" curriculum in reducing coronary heart disease risk factors among black elementary and junior high school students. The evaluation, part of a five-year longitudinal study, linked effectiveness of teachers' implementation with student outcomes and identified program weaknesses during implementation. Teachers with higher effectiveness scores had significantly more favorable student outcomes in systolic blood pressure, diastolic blood pressure, HDL cholesterol, HDL/cholesterol ratio, serum thiocyanate, and fitness. Of 82 teachers, 38 (46%) had scores reflecting effective teaching. Lack of time and commitment and inadequate use of the behavioral teaching approach demanded by the curriculum contributed most to implementation failure. Teachers as insufficient role models emerged as an important factor. Future research needs appropriate reinforcement of teacher participation and measurement of the environmental factors and personal teacher characteristics that may affect program implementation. School health education programs need an intensive training component that will enable teachers to adopt behavioral teaching approaches, promote teacher's examination and change of their personal risk factors, and stress the classroom dynamic of teachers as role models.

Cardiovascular risk factor prevention in black schoolchildren: two-year results of the "Know Your Body" program.

A five-year intervention study of the effectiveness of the "Know Your Body" program in reducing coronary heart disease risk factors among black students in the District of Columbia, who were in grades 4-6 at baseline, was begun in 1983. Nine schools were stratified on socioeconomic status and randomly assigned to control and intervention groups. The "Know Your Body" curriculum focuses on nutrition, fitness, and the prevention of cigarette smoking. At baseline, 1,234 students were eligible for the screening in which the following target risk factors were measured: systolic and diastolic blood pressures, ponderosity index, triceps skinfold thickness, postexercise pulse recovery rate, serum total and high density lipoprotein (HDL) cholesterol, and serum thiocyanate. After two years of intervention, results indicated that the program may have had a favorable impact on the following risk factors: systolic and diastolic pressures, HDL cholesterol, ratio of total to HDL cholesterol, fitness (postexercise pulse recovery rate), and smoking. Significant net changes in the favorable direction also were found for health knowledge and attitude toward smoking. Blood pressure reduction was associated with decreased ponderosity and improved fitness, and increased HDL cholesterol was associated with decreased ponderosity. These results are consistent with other evaluations of the "Know Your Body" program, suggesting that the program may be effective in reducing chronic disease risk in diverse school populations.

Cardiovascular risk factors among black schoolchildren: comparisons among four Know Your Body studies.

Baseline cardiovascular risk factor variables were obtained from 1,041 black District of Columbia children in Grades 4-6 as part of a Know Your Body evaluation project. Screening included height, weight, triceps skinfold measurements, systolic and diastolic blood pressures, step-test for fitness, serum cholesterol, high-density lipoprotein cholesterol and thiocyanate. Results were compared with those in three other Know Your Body studies, Bronx, New York, Westchester, New York, and Los Angeles, and indicated that District of Columbia black children are more likely to have high cholesterol levels and to fail the fitness test than black children in the other studies. In the District of Columbia, obese children had significantly higher total serum cholesterol, systolic, diastolic, and high-density lipoprotein levels, and were less fit than other District of Columbia children; almost three-fourths of all of the children had one or more risk factors. Socioeconomic status was negatively correlated with diastolic blood pressure, skinfold thickness, and cholesterol levels and was positively correlated with high-density lipoprotein cholesterol. Rates of obesity and diastolic blood pressure were consistent with Bronx and Westchester comparisons suggesting that socioeconomic status interacts with ethnicity to determine risk factor levels. The existence of children with multiple risk factors in all of the Know Your Body studies supports the need for early intervention.

Cardiovascular risk factor prevention in black school children: the "Know Your Body" evaluation project.

A longitudinal study of the effectiveness of the "Know Your Body" (KYB) program in reducing coronary heart disease risk factors was begun among black students in the District of Columbia in 1983. Subjects were in grades four through six at nine schools stratified on socioeconomic status and randomized into one control and two intervention groups. At baseline, 1,041 students were measured for systolic and diastolic blood pressure, ponderosity, triceps skinfold thickness, postexercise pulse recovery rate, serum thiocyanate, serum total cholesterol, and serum HDL cholesterol. Significant net changes in individual values occurred in the favorable direction at one or all four annual follow-up reexaminations for systolic blood pressure, diastolic blood pressure, HDL cholesterol, HDL/total cholesterol ratio, serum thiocyanate, and fitness. Favorable changes in diastolic blood pressure and serum thiocyanate were observed at all reexaminations, and these were substantiated by analyses that used the school grade as the unit of analysis. Intervention students who were judged to have had the best KYB teachers showed significant favorable net changes in total serum cholesterol after one year. Results are consistent with other evaluations of the Know Your Body program suggesting that KYB may reduce chronic disease risk in diverse school populations, and that increased efforts should be made to improve implementation methods.

Adapting a self-management education program for asthma for use in an outpatient clinic.

A self-management patient education program for children with asthma which incorporates a slide tape program, pamphlets, nurse discussion, and physician discussion has been adapted from an emergency room site to an outpatient clinic for use during routine asthma clinic visits. Pre-interviews and post-interviews with and medical record review of 12 patients, aged 4 to 12 years, demonstrated that the children had statistically significant increases in knowledge of self-management skills (recognition of asthma triggers and early warning signs and appropriate behaviors to manage acute episodes) and a significant increase in the sense of personal control (Health Locus of Control). Parents reported less disruption of family activities due to asthma and that the children had increased their use of asthma self-management techniques, resulting in improved management of asthma at home. Nurse and physician response to the program was enthusiastic and demonstrated the feasibility of integrating patient education into the outpatient clinic medical care routine.