Older adults with multi-morbidity: medication management processes and design implications for personal health applications

Background

Older adults often have multiple chronic problems requiring them to manage complex medication regimens overseen by various clinicians. Personal health applications (PHAs) show promise assisting in medication self-management, but adoption of new computer technologies by this population is challenging. Optimizing the utility of PHAs requires a thorough understanding of older adults’ needs, preferences, and practices.

Objective

The objective of our study was to understand the medication self-management issues faced by older adults and caregivers that can be addressed by an electronic PHA.

Methods

We conducted a qualitative analysis of a series of individual and group semistructured interviews with participants who were identified through purposive sampling.

Results

We interviewed 32 adult patients and 2 adult family caregivers. We identified 5 core themes regarding medication self-management challenges: seeking reliable medication information, maintaining autonomy in medication treatment decisions, worrying about taking too many medications, reconciling information discrepancies between allopathic and alternative medical therapies, and tracking and coordinating health information between multiple providers.

Conclusions

This study provides insights into the latent concerns and challenges faced by older adults and caregivers in managing medications. The results suggest that PHAs should have the following features to accommodate the management strategies and information preferences of this population: (1) provide links to authoritative and reliable information on side effects, drug interactions, and other medication-related concerns in a way that is clear, concise, and easy to navigate, (2) facilitate communication between patients and doctors and pharmacists through electronic messaging and health information exchange, and (3) provide patients the ability to selectively disclose medication information to different clinicians.     

基于微信平台的健康管理模式在胫骨平台骨折患者术后康复中的应用研究

目的探讨利用微信平台健康管理模式对胫骨平台骨折(TPF)患者术后康复效果的影响。 方法选取2014年1月至2016年12月海军军医大学附属长海医院战创伤急救中心收治的120例TPF患者为研究对象,利用随机数字表法将患者分为微信组及对照组,每组60例。微信组患者应用微信建群模式进行点对点、点对面三维立体式管理;对照组患者实施常规门诊随访指导;两组干预时间均为10个月。对患者远期并发症关节僵硬、创伤性关节炎进行观察和客观评估,数据行χ²检验。在干预前后分别对两组患者进行Rasmussen临床分级评估,评估内容为功能、疼痛、活动范围、屈曲畸形、肌力、稳定性;并应用骨折术后生活水平调查问卷对两组患者干预前后疾病认知度、治疗重视度、医嘱执行度、日常活动改善情况、焦虑紧张度、术后恢复满意度进行调查评分,数据行t检验。 结果微信组患者发生术后远期并发症关节僵硬、创伤性关节炎分别是5、3例,显著少于对照组(12、8例),差异均有统计学意义(χ²＝3.358、2.502,P值均小于0.05)。干预前,两组患者Rasmussen临床分级评分比较差异均无统计学意义(P值均大于0.05);对照组患者干预后Rasmussen临床分级评分高于干预前,差异均有统计学意义(P值均小于0.05);微信组患者干预后Rasmussen临床分级评分中功能、疼痛、活动范围、屈曲畸形、肌力、稳定性的评分分别为(16.89±4.14)、(24.33±4.42)、(13.93±3.12)、(7.17±2.42)、(7.12±2.54)、(7.15±2.59)分];高于干预前[(6.78±2.82)、(5.78±1.87)、(5.84±1.97)、(2.71±1.09)、(2.67±1.02)、(2.45±0.88)分],差异均有统计学意义(t＝39.739、19.841、14.462、12.129、20.571、9.676,P值均小于0.05),且高于干预后对照组对应的评分[(12.91±3.12)、(20.76±3.92)、(10.78±2.83)、(5.78±1.82)、(5.65±1.78)、(5.62±1.82)分,差异均有统计学意义(t＝4.657、3.199、3.486、2.798、2.049、2.506,P<0.05、＝0.003、0.001、0.008、0.047、0.017)。干预前,两组患者生活水平评分比较,差异均无统计学意义(P值均大于0.05);对照组患者干预后生活水平评分低于干预前;微信组患者干预后生活水平评分中疾病认知度、治疗重视度、医嘱执行度、日常活动改善、焦虑紧张度、术后恢复满意度的评分分别为(1.01±0.32)、(0.78±0.22)、(1.12±0.13)、(1.04±0.21)、(0.76±0.12)、(1.06±0.14)分,低于干预前[(3.01±0.82)、(2.89±0.79)、(3.21±0.62)、(2.99±0.71)、(3.21±0.63)、(3.10±0.76)分],差异均有统计学意义(t＝15.667、17.899、18.006、11.103、13.516、10.376,P值均小于0.05),且低于干预后对照组的评分[(2.13±0.42)、(1.89±0.62)、(1.89±0.31)、(1.68±0.46)、(1.64±0.33)、(1.88±0.34)分],差异均有统计学意义(t＝8.542、5.060、10.376、4.819、5.940、9.000,P值均小于0.05)。 结论微信管理对患者实施健康管理具有积极的影响,能够减少术后远期并发症,提高患者膝关节活动功能,并能提高患者生活质量。     

An international course on strategic information management for medical informatics students: aim, content, structure, and experiences

We report on a course for medical informatics students on hospital information systems, especially on its strategic information management. Starting as course at the Medical Informatics Program of the University of Heidelberg/University of Applied Sciences Heilbronn, it is now organized as international course in the framework of the International Partnership for Health Informatics Education (http:// www.iphie.org) jointly for medical information science students from the University of Amsterdam, medical informatics students, as well as health information management students from the Universities of Heidelberg/Heilbronn. In 2002, medical informatics students from the Master of Science program of the newly founded University for Health Informatics and Technology Tyrol (UMIT) at Innsbruck, Austria, joined. We report about the aim of this course, its audience, and the educational programs involved, about its content and structure, as well as about our experiences gained so far.     

Utilizing the Wikidata System to Improve the Quality of Medical Content in Wikipedia in Diverse Languages: A Pilot Study

Background

Wikipedia is an important source of medical information for both patients and medical professionals. Given its wide reach, improving the quality, completeness, and accessibility of medical information on Wikipedia could have a positive impact on global health.

Objective

We created a prototypical implementation of an automated system for keeping drug-drug interaction (DDI) information in Wikipedia up to date with current evidence about clinically significant drug interactions. Our work is based on Wikidata, a novel, graph-based database backend of Wikipedia currently in development.

Methods

We set up an automated process for integrating data from the Office of the National Coordinator for Health Information Technology (ONC) high priority DDI list into Wikidata. We set up exemplary implementations demonstrating how the DDI data we introduced into Wikidata could be displayed in Wikipedia articles in diverse languages. Finally, we conducted a pilot analysis to explore if adding the ONC high priority data would substantially enhance the information currently available on Wikipedia.

Results

We derived 1150 unique interactions from the ONC high priority list. Integration of the potential DDI data from Wikidata into Wikipedia articles proved to be straightforward and yielded useful results. We found that even though the majority of current English Wikipedia articles about pharmaceuticals contained sections detailing contraindications, only a small fraction of articles explicitly mentioned interaction partners from the ONC high priority list. For 91.30% (1050/1150) of the interaction pairs we tested, none of the 2 articles corresponding to the interacting substances explicitly mentioned the interaction partner. For 7.21% (83/1150) of the pairs, only 1 of the 2 associated Wikipedia articles mentioned the interaction partner; for only 1.48% (17/1150) of the pairs, both articles contained explicit mentions of the interaction partner.

Conclusions

Our prototype demonstrated that automated updating of medical content in Wikipedia through Wikidata is a viable option, albeit further refinements and community-wide consensus building are required before integration into public Wikipedia is possible. A long-term endeavor to improve the medical information in Wikipedia through structured data representation and automated workflows might lead to a significant improvement of the quality of medical information in one of the world’s most popular Web resources.     

Individuals Appreciate Having Their Medication Record on the Web: A Survey of Attitudes to a National Pharmacy Register

Background

Many patients receive health care in different settings. Thus, a limitation of clinical care may be inaccurate medication lists, since data exchange between settings is often lacking and patients do not regularly self-report on changes in their medication. Health care professionals and patients are both interested in utilizing electronic health information. However, opinion is divided as to who should take responsibility for maintaining personal health records. In Sweden, the government has passed a law to enforce and fund a national register of dispensed medications. The register comprises all individuals with dispensed medications (6.4 million individuals, September 2006) and can be accessed by the individual online via “My dispensed medications”. The individual has the right to restrict the accessibility of the information in health care settings.

Objective

The aim of the present study was to evaluate the users’ attitudes towards their access to “My dispensed medications” as part of a new interactive Internet service on prescribed medications.

Method

A password-protected Web survey was conducted among a first group of users of “My dispensed medications”. Data was anonymously collected and analyzed with regard to the usefulness and design of the Web site, the respondents’ willingness to discuss their “My dispensed medications” with others, their reasons for access, and their source of information about the service.

Results

During the study period (January-March, 2007), all 7860 unique site visitors were invited to answer the survey. Invitations were accepted by 2663 individuals, and 1716 responded to the online survey yielding a view rate of 21.8% (1716/7860) and a completion rate of 64.4% (1716/2663). The completeness rate for each question was in the range of 94.9% (1629/1716) to 99.5% (1707/1716). In general, the respondents’ expectations of the usefulness of “My dispensed medications” were high (total median grade 5; Inter Quartile Range [IQR] 3, on a scale 1-6). They were also positive about the design of the Web site (total median grade 5; IQR 1, on a scale 1-6). The high grades were not dependent on age or number of drugs. A majority of the respondents, 60.4% (1037/1716), had learned about “My dispensed medications” from pharmacies. 70.4% (1208/1716) of all respondents said they visited “My dispensed medications” to get control or an overview of their drugs. Getting control was a more common (P < .001) answer for the elderly (age 75 or above), whereas curiosity was more common (P < .001) for the younger age group (18-44 years).

Conclusion

We found that users of the provider-based personal medication record “My dispensed medications” appreciated the access to their record. Since we found that the respondents liked the design of the Web site and perceived that the information was easy to understand, the study provided no reason for system changes. However, a need for more information about the register, and to extend its use, was recognized.     

Herbal medication aggravates cataract formation: a case report

We report a case of complicated cataract aggravated after taking herbal medication for atopic dermatitis. An 11-yr-old boy was referred for the evaluation of decreased visual acuity in both eyes for 2 months. Past history showed that he had been diagnosed with atopic dermatitis when he was 1 yr old. He had been treated only with herbal medication for a period of 8 months prior to visiting our clinic. He had his visual acuity checked in a local ophthalmic clinic one year before, and the visual acuity was 20/20 in both eyes at that time. When attending our clinic the ophthalmologic examination showed that his best corrected visual acuity was 20/200 in both eyes. Lenses of both eyes had severe posterior subcapsular and posterior capsular opacity. Phacoemulsification, posterior chamber intraocular lens implantation, and posterior continuous curvilinear capsulectomy were performed in both eyes. After 3 months postoperatively, the best corrected visual acuity was recovered to 20/20 in both eyes without any complication. Our case suggests that there may be a risk of aggravation of cataract or development of cataract after treatment with some unidentified herbal medication in a patient with atopic dermatitis.     

Acceptability of a Personally Controlled Health Record in a Community-Based Setting: Implications for Policy and Design

Background

Consumer-centered health information systems that address problems related to fragmented health records and disengaged and disempowered patients are needed, as are information systems that support public health monitoring and research. Personally controlled health records (PCHRs) represent one response to these needs. PCHRs are a special class of personal health records (PHRs) distinguished by the extent to which users control record access and contents. Recently launched PCHR platforms include Google Health, Microsoft’s HealthVault, and the Dossia platform, based on Indivo.

Objective

To understand the acceptability, early impacts, policy, and design requirements of PCHRs in a community-based setting.

Methods

Observational and narrative data relating to acceptability, adoption, and use of a personally controlled health record were collected and analyzed within a formative evaluation of a PCHR demonstration. Subjects were affiliates of a managed care organization run by an urban university in the northeastern United States. Data were collected using focus groups, semi-structured individual interviews, and content review of email communications. Subjects included: n = 20 administrators, clinicians, and institutional stakeholders who participated in pre-deployment group or individual interviews; n = 52 community members who participated in usability testing and/or pre-deployment piloting; and n = 250 subjects who participated in the full demonstration of which n = 81 initiated email communications to troubleshoot problems or provide feedback. All data were formatted as narrative text and coded thematically by two independent analysts using a shared rubric of a priori defined major codes. Sub-themes were identified by analysts using an iterative inductive process. Themes were reviewed within and across research activities (ie, focus group, usability testing, email content review) and triangulated to identify patterns.

Results

Low levels of familiarity with PCHRs were found as were high expectations for capabilities of nascent systems. Perceived value for PCHRs was highest around abilities to co-locate, view, update, and share health information with providers. Expectations were lowest for opportunities to participate in research. Early adopters perceived that PCHR benefits outweighed perceived risks, including those related to inadvertent or intentional information disclosure. Barriers and facilitators at institutional, interpersonal, and individual levels were identified. Endorsement of a dynamic platform model PCHR was evidenced by preferences for embedded searching, linking, and messaging capabilities in PCHRs; by high expectations for within-system tailored communications; and by expectation of linkages between self-report and clinical data.

Conclusions

Low levels of awareness/preparedness and high expectations for PCHRs exist as a potentially problematic pairing. Educational and technical assistance for lay users and providers are critical to meet challenges related to: access to PCHRs, especially among older cohorts; workflow demands and resistance to change among providers; inadequate health and technology literacy; clarification of boundaries and responsibility for ensuring accuracy and integrity of health information across distributed data systems; and understanding confidentiality and privacy risks. Continued demonstration and evaluation of PCHRs is essential to advancing their use.     

Clinical information technology in hospitals: a comparison between the state of Iowa and two provinces in Canada

Despite the growing interest in adopting information technology (IT) in healthcare, the degree of technology sophistication varies among healthcare organizations. Changes in the health care sector and continuous pressure to improve the quality of care have driven the evolution of IT in hospitals. This paper provides an overview of clinical IT sophistication in a sample of U.S. hospitals, and compares clinical IT capacities in this sample with a sample of Canadian hospitals. The instrument used for the comparison measures three clinical dimensions of IT sophistication: functional sophistication, technological sophistication and integration level. Clinical areas that were considered include patient management, patient care activities and clinical support activities. The comparison between hospitals in Iowa and Canada shows differences in clinical IT sophistication between the two settings. Hospitals in Iowa appear to have more technologies but fewer computerized processes and integration of patient management activities. Technological sophistication however, was low in both samples. Our findings confirm the construct validity of the measurement instrument and show initial evidence of its generalizability. More initiatives using the instrument would lead to enhancement in IT assessment tools that can be used for evaluation of IT in relation to patient management and quality outcomes.     

Characteristics of health IT outage and suggested risk management strategies: An analysis of historical incident reports in China

BackgroundThe healthcare industry has become increasingly dependent on using information technology (IT) to manage its daily operations. Unexpected downtime of health IT systems could therefore wreak havoc and result in catastrophic consequences. Little is known, however, regarding the nature of failures of health IT.ObjectiveTo analyze historical health IT outage incidents as a means to better understand health IT vulnerabilities and inform more effective prevention and emergency response strategies.MethodsWe studied news articles and incident reports publicly available on the internet describing health IT outage events that occurred in China. The data were qualitatively analyzed using a deductive grounded theory approach based on a synthesized IT risk model developed in the domain of information systems.ResultsA total of 116 distinct health IT incidents were identified. A majority of them (69.8%) occurred in the morning; over 50% caused disruptions to the patient registration and payment collection functions of the affected healthcare facilities. The outpatient practices in tertiary hospitals seem to be particularly vulnerable to IT failures. Software defects and overcapacity issues, followed by malfunctioning hardware, were among the principal causes.ConclusionsUnexpected health IT downtime occurs more and more often with the widespread adoption of electronic systems in healthcare. Risk identification and risk assessments are essential steps to developing preventive measures. Equally important is institutionalization of contingency plans as our data show that not all failures of health IT can be predicted and thus effectively prevented. The results of this study also suggest significant future work is needed to systematize the reporting of health IT outage incidents in order to promote transparency and accountability.     

27颊侧罕见多生牙尖的CBCT诊断与鉴别诊断

目的　利用锥形束CT（Cone Beam Computer Tomography,CBCT）确诊27颊侧多生牙尖1例,并对其鉴别诊断、发生机制及CBCT的临床应用特点进行分析。 方法　本文根据口腔临床一般检查、口腔局部X线片并结合CBCT对患牙进行确诊;对多生牙尖、融合牙、双生牙、结合牙各自的特点及鉴别要点分析讨论。 结果　根据口腔临床一般检查、口腔局部X线片, 特别是应用CBCT确诊了1例左上第2磨牙颊侧多生牙尖。 结论　口腔辅助检查是临床上确诊口腔颌面部疾病的必要手段。CBCT具有扫描时间短、辐射剂量小、扫描灵活、分辨率高等优点,提高了各类口腔疾病的诊疗水平。     

The Effects on Health Behavior and Health Outcomes of Internet-Based Asynchronous Communication Between Health Providers and Patients With a Chronic Condition: A Systematic Review

Background

In support of professional practice, asynchronous communication between the patient and the provider is implemented separately or in combination with Internet-based self-management interventions. This interaction occurs primarily through electronic messaging or discussion boards. There is little evidence as to whether it is a useful tool for chronically ill patients to support their self-management and increase the effectiveness of interventions.

Objective

The aim of our study was to review the use and usability of patient-provider asynchronous communication for chronically ill patients and the effects of such communication on health behavior, health outcomes, and patient satisfaction.

Methods

A literature search was performed using PubMed and Embase. The quality of the articles was appraised according to the National Institute for Health and Clinical Excellence (NICE) criteria. The use and usability of the asynchronous communication was analyzed by examining the frequency of use and the number of users of the interventions with asynchronous communication, as well as of separate electronic messaging. The effectiveness of asynchronous communication was analyzed by examining effects on health behavior, health outcomes, and patient satisfaction.

Results

Patients’ knowledge concerning their chronic condition increased and they seemed to appreciate being able to communicate asynchronously with their providers. They not only had specific questions but also wanted to communicate about feeling ill. A decrease in visits to the physician was shown in two studies (P=.07, P=.07). Increases in self-management/self-efficacy for patients with back pain, dyspnea, and heart failure were found. Positive health outcomes were shown in 12 studies, where the clinical outcomes for diabetic patients (HbA1c level) and for asthmatic patients (forced expiratory volume [FEV]) improved. Physical symptoms improved in five studies. Five studies generated a variety of positive psychosocial outcomes.

Conclusions

The effect of asynchronous communication is not shown unequivocally in these studies. Patients seem to be interested in using email. Patients are willing to participate and are taking the initiative to discuss health issues with their providers. Additional testing of the effects of asynchronous communication on self-management in chronically ill patients is needed.     

Influences, usage, and outcomes of Internet health information searching: multivariate results from the Pew surveys

This paper provides results from seven major nationally representative datasets (two in detail) from the Pew Internet and American Life Project to answer two primary questions: (1) what influences people to seek online health information and (2) what influences their perceived outcomes from having access to this information? Cross-tabulations, logistic regressions, and multidimensional scaling are applied to these survey datasets. The strongest and most consistent influences on ever, or more frequently, using the Internet to search for health information were sex (female), employment (not fulltime), engaging in more other Internet activities, more specific health reasons (diagnosed with new health problem, ongoing medical condition, prescribed new medication or treatment), and helping another deal with health issues. Internet health seeking is consistently similar to general Internet activities such as email, news, weather, and sometimes hobbies. A variety of outcomes from or positive assessments of searching for Internet health information are predicted most strongly by sex (female), engaging in other Internet activities, Internet health information seeking including more frequent health seeking, more specific health reasons, belonging to an online support group sharing health interests, and helping another deal with an illness or major health condition.     

Desmoplastic fibroma of the scapula with fluorodeoxyglucose uptake on positron emission tomography: a case report and literature review

We present a case of desmoplastic fibroma (DF) arising from the right scapula that was incidentally identified by fluorodeoxyglucose-positron emission tomography (FDG-PET) imaging performed to evaluate the presence of metastasis due to a history of surgical treatment for endometrioid adenocarcinoma. A 65-year-old woman was admitted to our hospital for consultation about a bone lesion in the right scapula although she was asymptomatic. FDG-PET revealed moderate focal ¹⁸F-FDG uptake in the right scapula with a maximal standardized uptake value of 3.2. The lower angle of the scapula was unclear on plain radiology. Needle biopsy was performed to make a differential diagnosis between primary bone and metastatic tumor. Pathologically, the tumor was composed of a relatively sparse proliferation of spindle-shaped fibroblastic/myofibroblastic cells in a dense collagenous background. Therefore, the diagnosis was a primary fibrous bone tumor. Wide excision was performed, because of the possibility of malignant tumors such as low-grade fibrosarcoma in light of the FDG-PET uptake. Pathologically, the resected tumor was composed of a proliferation of less atypical spindle cells in the collagenous stroma with focally myxoid change; no mitotic figures were observed. Immunohistochemically, β-catenin nuclear/cytoplasmic staining was not observed, and no β-catenin genetic mutations were detected. Therefore, the tumor was diagnosed as DF. DF is a tumor that exhibits FDG-PET uptake. There were no signs of recurrence 6 months after surgery.     

Adenocarcinoma cells in effusion cytology as a diagnostic pitfall with potential impact on clinical management: A case report with brief review of immunomarkers

Distinguishing metastatic carcinoma cells from reactive mesothelial cells in effusion samples is often challenging based on morphology alone. Metastatic carcinoma cells in fluid samples may mimic reactive mesothelial cells due to overlapping cytological features. We report a case of a pleural effusion in a 51‐year‐old female patient with a medical history significant for bilateral ovarian tumors and peritoneal implants diagnosed as serous tumor of borderline malignant potential. The effusion was composed almost entirely of adenocarcinoma cells that morphologically mimicked reactive mesothelial cells. The diagnosis of metastatic adenocarcinoma was made after a wide immunostaining panel of antibodies. Recognizing metastatic adenocarcinoma cells in effusion samples can be challenging and an accurate diagnosis may have significant impact on clinical management as demonstrated by this case. Diagn. Cytopathol. 2012;42:253–258. © 2012 Wiley Periodicals, Inc.     

A case report on a patient who presented with myelofibrosis,developed breast cancer with myeloid metaplasia,and finally showed immature NK-cell leukemia or AML without maturation with CD56 expression transformation in the pleura with extramedullary hematopoiesis: A 25-year course

This study reports a female patient who suffered from primary myelofibrosis at 38 years of age, breast cancer with myeloid metaplasia at 49 years of age, and pleural effusion and multiple subcutaneous nodules at 62 years of age. She was finally diagnosed with immature NK-cell leukemia or AML without maturation with CD56 expression transformation of extramedullary hematopoiesis that developed in the pleura, and died 11 months later. Atypical cells in the pleural effusion had surface markers of CD13, CD33, CD34, and CD56 using a fluorescence-activated cell sorter analysis, and were positive for myeloperoxidase, CD34, CD43, and CD56 in a cell block material using an immunohistochemical method. Megakaryocytic and erythroblastic cells were also seen in the pleural effusion.