Population informatics-based system to improve osteoporosis screening in women in a primary care practice

Objective

To study the effects of using a population-based informatics system for osteoporosis screening and treatment in women aged 65 years or older.

Design

A population-based informatics system (PRECARES: PREventive CAre REminder System) was implemented to meet the needs of the workflow of a primary care practice. Patients treated in either of two sections of a primary care internal medicine department were selected for the intervention, and patients of a comparable third section served as the control group. PRECARES identified women in the intervention group who were due for osteoporosis screening on the basis of age and who had no record of previous screening in our clinical system. If these eligible patients did not have an upcoming outpatient appointment, appointment secretaries sent a letter requesting that they call to make an appointment for a dual-energy x-ray absorptiometry scan.

Measurements

At baseline and 3 months after the letters were sent, a database was used to determine the rate of osteoporosis screening in the intervention and control groups.

Results

A total of 689 patients in the intervention group were sent the letter. Three months after the letters were sent, the rate of osteoporosis screening was 76.4% (2409/3152) in the intervention group vs 69% (928/1344) in the control group (p<0.001). In the intervention group, 25% of the 689 patients responded to the letter and completed osteoporosis screening. Patients who had osteoporosis screening received appropriate treatment.

Conclusion

A population-based informatics system for primary care practice significantly improved the rate of osteoporosis screening.     

Factors Associated with Sexually Transmitted Infections Among Young Ghanaian Women

Objective

To identify factors associated with a history of sexually transmitted infections in Ghanaian women 15 – 24 years.

Design

The study was a cross-sectional data analysis of 1280 sexually experienced females from the 2003 Ghana Demographic Health Survey. Using chi square and t-test, those with a history or symptoms of STI were compared with those denying such a history on demographic, individual and partner level variables. Significant variables were entered into logistic regression to identify variables associated with STI.

Results

The STI group comprised 12% of the study population. Compared to those denying a history of STI, the STI group was less likely to know where to get condoms (37% vs 23%, p=.001) but more likely to use a condom at their last sexual encounter (27% vs 17%, p=.003). Women in the STI group were significantly less likely to discuss family planning with their partners but more likely to have 2 or more partners in the preceding 12 months. Logistic regression showed that factors associated with STI among sexually active Ghanaian female youth included not knowing where to get condoms and not discussing family planning with partner.

Conclusion

Majority of sexually experienced Ghanaian female youth do not know where to get condoms. Lack of knowledge of source of condoms was identified as a risk factor for STI for these women.     

Commercial off-the-shelf consumer health informatics interventions: recommendations for their design,evaluation and redesign

Objective

The goal of this paper is to describe the successful application of a use case-based evaluation approach to guide the effective design, evaluation and redesign of inexpensive, commercial, off-the-shelf consumer health informatics (CHI) interventions.

Design

Researchers developed four CHI intervention use cases representing two distinct patient populations (patients with diabetes with high blood pressure, post-bariatric surgery patients), two commercial off-the-shelf CHI applications (Microsoft HealthVault, Google Health), and related devices (blood pressure monitor, pedometer, weight scale). Three patient proxies tested each intervention for 10 days.

Measurements

The patient proxies recorded their challenges while completing use case tasks, rating the severity of each challenge based on how much it hindered their use of the intervention. Two independent evaluators categorized the challenges by human factors domain (physical, cognitive, macroergonomic).

Results

The use case-based approach resulted in the identification of 122 challenges, with 12% physical, 50% cognitive and 38% macroergonomic. Thirty-nine challenges (32%) were at least moderately severe. Nine of 22 use case tasks (41%) accounted for 72% of the challenges.

Limitations

The study used two patient proxies and addressed two specific patient populations and low-cost, off-the-shelf CHI interventions, which may not perfectly generalize to a larger number of proxies, actual patient populations, or other CHI interventions.

Conclusion

CHI designers can employ the use case-based evaluation approach to assess the fit of a CHI intervention with patients'' health work, in the context of their daily activities and environment, which would be difficult or impossible to evaluate by laboratory-based studies.     

Formulation of a model for automating infection surveillance: algorithmic detection of central-line associated bloodstream infection

Objective

To formulate a model for translating manual infection control surveillance methods to automated, algorithmic approaches.

Design

We propose a model for creating electronic surveillance algorithms by translating existing manual surveillance practices into automated electronic methods. Our model suggests that three dimensions of expert knowledge be consulted: clinical, surveillance, and informatics. Once collected, knowledge should be applied through a process of conceptualization, synthesis, programming, and testing.

Results

We applied our framework to central vascular catheter associated bloodstream infection surveillance, a major healthcare performance outcome measure. We found that despite major barriers such as differences in availability of structured data, in types of databases used and in semantic representation of clinical terms, bloodstream infection detection algorithms could be deployed at four very diverse medical centers.

Conclusions

We present a framework that translates existing practice—manual infection detection—to an automated process for surveillance. Our experience details barriers and solutions discovered during development of electronic surveillance for central vascular catheter associated bloodstream infections at four hospitals in a variety of data environments. Moving electronic surveillance to the next level—availability at a majority of acute care hospitals nationwide—would be hastened by the incorporation of necessary data elements, vocabularies and standards into commercially available electronic health records.     

Methodologic Issues in Health Informatics Trials: The Complexities of Complex Interventions

Objective

All electronic health (e-health) interventions require validation as health information technologies, ideally in randomized controlled trial settings. However, as with other types of complex interventions involving various active components and multiple targets, health informatics trials often experience problems of design, methodology, or analysis that can influence the results and acceptance of the research. Our objective was to review selected key methodologic issues in conducting and reporting randomized controlled trials in health informatics, provide examples from a recent study, and present practical recommendations.

Design

For illustration, we use the COMPETE III study, a large randomized controlled clinical trial investigating the impact of a shared decision-support system on the quality of vascular disease management in Ontario, Canada.

Results

We describe a set of methodologic, logistic, and statistical issues that should be considered when planning and implementing trials of complex e-health interventions, and provide practical recommendations for health informatics trialists.

Conclusions

Our recommendations emphasize validity and pragmatic considerations and would be useful for health informaticians conducting or evaluating e-health studies.     

Training Multidisciplinary Biomedical Informatics Students: Three Years of Experience

Objective

The European INFOBIOMED Network of Excellence ¹ recognized that a successful education program in biomedical informatics should include not only traditional teaching activities in the basic sciences but also the development of skills for working in multidisciplinary teams.

Design

A carefully developed 3-year training program for biomedical informatics students addressed these educational aspects through the following four activities: (1) an internet course database containing an overview of all Medical Informatics and BioInformatics courses, (2) a BioMedical Informatics Summer School, (3) a mobility program based on a ‘brokerage service’ which published demands and offers, including funding for research exchange projects, and (4) training challenges aimed at the development of multi-disciplinary skills.

Measurements

This paper focuses on experiences gained in the development of novel educational activities addressing work in multidisciplinary teams. The training challenges described here were evaluated by asking participants to fill out forms with Likert scale based questions. For the mobility program a needs assessment was carried out.

Results

The mobility program supported 20 exchanges which fostered new BMI research, resulted in a number of peer-reviewed publications and demonstrated the feasibility of this multidisciplinary BMI approach within the European Union. Students unanimously indicated that the training challenge experience had contributed to their understanding and appreciation of multidisciplinary teamwork.

Conclusion

The training activities undertaken in INFOBIOMED have contributed to a multi-disciplinary BMI approach. It is our hope that this work might provide an impetus for training efforts in Europe, and yield a new generation of biomedical informaticians.     

Patient characteristics associated with venous thromboembolic events: a cohort study using pooled electronic health record data

Objective

To demonstrate the potential of de-identified clinical data from multiple healthcare systems using different electronic health records (EHR) to be efficiently used for very large retrospective cohort studies.

Materials and methods

Data of 959 030 patients, pooled from multiple different healthcare systems with distinct EHR, were obtained. Data were standardized and normalized using common ontologies, searchable through a HIPAA-compliant, patient de-identified web application (Explore; Explorys Inc). Patients were 26 years or older seen in multiple healthcare systems from 1999 to 2011 with data from EHR.

Results

Comparing obese, tall subjects with normal body mass index, short subjects, the venous thromboembolic events (VTE) OR was 1.83 (95% CI 1.76 to 1.91) for women and 1.21 (1.10 to 1.32) for men. Weight had more effect then height on VTE. Compared with Caucasian, Hispanic/Latino subjects had a much lower risk of VTE (female OR 0.47, 0.41 to 0.55; male OR 0.24, 0.20 to 0.28) and African-Americans a substantially higher risk (female OR 1.83, 1.76 to 1.91; male OR 1.58, 1.50 to 1.66). This 13-year retrospective study of almost one million patients was performed over approximately 125 h in 11 weeks, part time by the five authors.

Discussion

As research informatics tools develop and more clinical data become available in EHR, it is important to study and understand unique opportunities for clinical research informatics to transform the scale and resources needed to perform certain types of clinical research.

Conclusions

With the right clinical research informatics tools and EHR data, some types of very large cohort studies can be completed with minimal resources.     

Efficacy of single dose Nevirapine in reducing viral load in HIV positive mother in labour and transmission of HIV infection to new born babies as part of prevention of parent to child transmission

Background

Prevention of parent to child transmission (PPTCT) program was initiated in Armed Forces to reduce the vertical transmission of HIV by instituting single dose Nevirapine (sdNVP) in untreated HIV positive mothers in labour. The aim of this study was to evaluate the role of sdNVP to decrease viral load of HIV infected mother during labour and its efficacy in prevention of mother to child transmission of HIV.

Methods

Thirty antenatal women tested positive for HIV at our PPTCT centre and delivered between Jan 2006 and May 2008 were evaluated. During labour these women were given sdNVP. Newborns were given syrup Nevirapine. The babies were tested for HIV infection at 48 h and six weeks after delivery.

Results

Thirty HIV positive women delivered at our centre and four newborns were found positive for HIV infection at 48 h. After six weeks interval three neonates were detected for HIV infection as one infant at six weeks was found to be negative for HIV infection.

Conclusion

The protection rate of Nevirapine in untreated HIV positive women is not ideal. It is recommended that all HIV positive women should be offered Highly Active Antiretroviral therapy as primary mode for PPTCT.     

Late-stage disease at presentation to an HIV clinic in eastern Tanzania: A retrospective cross-sectional study

Background

Late presentation and delayed treatment initiation is associated with poor outcomes in patients with HIV. Little is known about the stage at which HIV patients present at HIV clinics in Tanzania.

Aim

This study aimed at determining the proportion of HIV patients presenting with WHO clinical stages 3 and 4 disease, and the level of immunity at the time of enrollment at the care and treatment center.

Methods

A retrospective cross-sectional study was conducted among 366 HIV-infected adults attending HIV clinic at Mwananyamala Hospital in Dar es Salaam, Tanzania. Data were obtained from the care and treatment clinic database.

Results

Late stage disease at the time of presentation was found in 276 (75.4%) of the patients; out of whom 153 (41.8%) presented with CD4 count <200 cells/ul and 229 (62.6%) presented with WHO clinical stage 3 or 4 at the time of clinic enrollment. Strategies to improve early diagnosis and treatment initiation should be improved.     

Evaluation of computer-generated reminders to improve CD4 laboratory monitoring in sub-Saharan Africa: a prospective comparative study

Objective

Little evidence exists on effective interventions to integrate HIV-care guidelines into practices within developing countries. This study tested the hypothesis that clinical summaries with computer-generated reminders could improve clinicians'' compliance with CD4 testing guidelines in the resource-limited setting of sub-Saharan Africa.

Design

A prospective comparative study of two randomly selected outpatient adult HIV clinics in western Kenya. Printed summaries with reminders for overdue CD4 tests were made available to clinicians in the intervention clinic but not in the control clinic.

Measurements

Changes in order rates for overdue CD4 tests were compared between and within the two clinics.

Results

The computerized reminder system identified 717 encounters (21%) with overdue CD4 tests. Analysis by study assignment (regardless of summaries being printed or not) revealed that with computer-generated reminders, CD4 order rates were significantly higher in the intervention clinic compared to the control clinic (53% vs 38%, OR=1.80, CI 1.34 to 2.42, p<0.0001). When comparison was restricted to encounters where summaries with reminders were printed, order rates in intervention clinic were even higher (63%). The intervention clinic increased CD4 ordering from 42% before reminders to 63% with reminders (50% increase, OR=2.32, CI 1.67 to 3.22, p<0.0001), compared to control clinic with only 8% increase from prestudy baseline (CI 0.83 to 1.46, p=0.51).

Limitations

Evaluation was conducted at two clinics in a single institution.

Conclusions

Clinical summaries with computer-generated reminders significantly improved clinician compliance with CD4 testing guidelines in the resource-limited setting of sub-Saharan Africa. This technology can have broad applicability to improve quality of HIV care in these settings.     

Effectiveness of Topic-specific Infobuttons: A Randomized Controlled Trial

Objective

Infobuttons are decision support tools that provide links within electronic medical record systems to relevant content in online information resources. The aim of infobuttons is to help clinicians promptly meet their information needs. The objective of this study was to determine whether infobutton links that direct to specific content topics (“topic links”) are more effective than links that point to general overview content (“nonspecific links”).

Design

Randomized controlled trial with a control and an intervention group. Clinicians in the control group had access to nonspecific links, while those in the intervention group had access to topic links.

Measurements

Infobutton session duration, number of infobutton sessions, session success rate, and the self-reported impact that the infobutton session produced on decision making.

Results

The analysis was performed on 90 subjects and 3,729 infobutton sessions. Subjects in the intervention group spent 17.4% less time seeking for information (35.5 seconds vs. 43 seconds, p = 0.008) than those in the control group. Subjects in the intervention group used infobuttons 20.5% (22 sessions vs. 17.5 sessions, p = 0.21) more often than in the control group, but the difference was not significant. The information seeking success rate was equally high in both groups (89.4% control vs. 87.2% intervention, p = 0.99). Subjects reported a high positive clinical impact (i.e., decision enhancement or knowledge update) in 62% of the sessions.

Limitations

The exclusion of users with a low frequency of infobutton use and the focus on medication-related information needs may limit the generalization of the results. The session outcomes measurement was based on clinicians'' self-assessment and therefore prone to bias.

Conclusion

The results support the hypothesis that topic links are more efficient than nonspecific links regarding the time seeking for information. It is unclear whether the statistical difference demonstrated will result in a clinically significant impact. However, the overall results confirm previous evidence that infobuttons are effective at helping clinicians to answer questions at the point of care and demonstrate a modest incremental change in the efficiency of information delivery for routine users of this tool.     

Key principles for a national clinical decision support knowledge sharing framework: synthesis of insights from leading subject matter experts

Objective

To identify key principles for establishing a national clinical decision support (CDS) knowledge sharing framework.

Materials and methods

As part of an initiative by the US Office of the National Coordinator for Health IT (ONC) to establish a framework for national CDS knowledge sharing, key stakeholders were identified. Stakeholders'' viewpoints were obtained through surveys and in-depth interviews, and findings and relevant insights were summarized. Based on these insights, key principles were formulated for establishing a national CDS knowledge sharing framework.

Results

Nineteen key stakeholders were recruited, including six executives from electronic health record system vendors, seven executives from knowledge content producers, three executives from healthcare provider organizations, and three additional experts in clinical informatics. Based on these stakeholders'' insights, five key principles were identified for effectively sharing CDS knowledge nationally. These principles are (1) prioritize and support the creation and maintenance of a national CDS knowledge sharing framework; (2) facilitate the development of high-value content and tooling, preferably in an open-source manner; (3) accelerate the development or licensing of required, pragmatic standards; (4) acknowledge and address medicolegal liability concerns; and (5) establish a self-sustaining business model.

Discussion

Based on the principles identified, a roadmap for national CDS knowledge sharing was developed through the ONC''s Advancing CDS initiative.

Conclusion

The study findings may serve as a useful guide for ongoing activities by the ONC and others to establish a national framework for sharing CDS knowledge and improving clinical care.     

How is the electronic health record being used? Use of EHR data to assess physician-level variability in technology use

Background

Studies of the effects of electronic health records (EHRs) have had mixed findings, which may be attributable to unmeasured confounders such as individual variability in use of EHR features.

Objective

To capture physician-level variations in use of EHR features, associations with other predictors, and usage intensity over time.

Methods

Retrospective cohort study of primary care providers eligible for meaningful use at a network of federally qualified health centers, using commercial EHR data from January 2010 through June 2013, a period during which the organization was preparing for and in the early stages of meaningful use.

Results

Data were analyzed for 112 physicians and nurse practitioners, consisting of 430 803 encounters with 99 649 patients. EHR usage metrics were developed to capture how providers accessed and added to patient data (eg, problem list updates), used clinical decision support (eg, responses to alerts), communicated (eg, printing after-visit summaries), and used panel management options (eg, viewed panel reports). Provider-level variability was high: for example, the annual average proportion of encounters with problem lists updated ranged from 5% to 60% per provider. Some metrics were associated with provider, patient, or encounter characteristics. For example, problem list updates were more likely for new patients than established ones, and alert acceptance was negatively correlated with alert frequency.

Conclusions

Providers using the same EHR developed personalized patterns of use of EHR features. We conclude that physician-level usage of EHR features may be a valuable additional predictor in research on the effects of EHRs on healthcare quality and costs.     

Prevalence of HIV seropositivity among patients with squamous cell carcinoma of the conjunctiva

Objective

To determine the prevalence of HIV seropositivity among patients with squamous cell carcinoma of the conjunctiva.

Methods

All patients with clinical and histopathological confirmation of squamous cell carcinoma seen during a ten year period (July 1999 to June 2009) were tested for HIV (Human Immunodeficiency Virus). The number of patients with squamous cell carcinoma of the conjunctiva who are HIV positive were counted.

Results

A total of thirty-three(33) eyes in thirty-two(32) patients were confirmed histopathologically to have conjunctival squamous cell carcinoma. Their ages ranged from 22 years to 66 years with a mean age of (38.6±11.8) years (SD). The male to female ratio was 1:1.5. Twenty four (75%) of these patients were HIV positive.

Conclusions

Squamous cell carcinoma is associated with the human immunodeficiency virus and is thus a marker for the disease in Benin City, Nigeria.     

Patient Trust in Physicians: Empirical Evidence from Shanghai,China

Background:

Patient trust in physicians, which can be considered a collective good, is necessary for an effective health care system. However, there is a widespread concern that patient trust in physicians is declining under various threats to the physician–patient relationship worldwide. This article aimed to assess patient trust in physicians through a quantitative study in Shanghai, China, and to provide appropriate suggestions for improving the trust in China.

Methods:

The data from a survey conducted in Zhongshan Hospital and Shanghai Tenth People''s Hospital, which are two tertiary public hospitals in Shanghai, were used in this study. Patient trust in physicians was the dependent variable. Furthermore, a 10-item scale was used to precisely describe the dependent variable. The demographic characteristics were independent variables of trust in physicians. Binomial logistic regression was employed to analyze the factors associated with the dependent variable, which was divided into two categories on the basis of the responses (1: Strongly agree or agree and 0: Strongly disagree, disagree, or neutral).

Results:

This study found that 67% of patients trusted or strongly trusted physicians. The mean score of patient trust in physicians was 35.4 from a total score of 50. Furthermore, patient trust in physicians was significantly correlated with the age, education level, annual income, and health insurance coverage of the patients.

Conclusions:

Patient trust in physicians in Shanghai, China is higher than previously reported. Furthermore, the most crucial reason for patient distrust in physicians is the information asymmetry between patients and physicians, which is a natural property of the physician–patient relationship, rather than the so-called for-profit characteristic of physicians or patients’ excessive expectations.     

Temporal reasoning over clinical text: the state of the art

Objectives

To provide an overview of the problem of temporal reasoning over clinical text and to summarize the state of the art in clinical natural language processing for this task.

Target audience

This overview targets medical informatics researchers who are unfamiliar with the problems and applications of temporal reasoning over clinical text.

Scope

We review the major applications of text-based temporal reasoning, describe the challenges for software systems handling temporal information in clinical text, and give an overview of the state of the art. Finally, we present some perspectives on future research directions that emerged during the recent community-wide challenge on text-based temporal reasoning in the clinical domain.     

Prevalence of HIV infection and the correlates among homeless in Tehran,Iran

Objective

To determine the prevalence of HIV infection among homeless men and women and the related risk behaviors in Tehran, Iran.

Methods

In 2007-2008, Tehran municipality stacked up 10 657 homeless men and women for assessment of HIV and began collaboration with Iranian Research Center for HIV/AIDS (IRCHA) departments to conduct HIV infection prevalence surveys in homeless populations. The results were analyzed for associations with demographic information, family support, status of drug abuse and relation with family and friends.

Results

Overall HIV prevalence was 1.7% (95% confidence interval 1.4-1.9). Factors independently associated with HIV infection included history of using drugs [AOR 8.15 (4.86-13.67)], older age [AOR 1.80 (1.08-2.99) for 40- 55 yr], occupation [AOR 1.64 (1.19-2.24) for unemployed], and no relation with family [AOR 1.82 (1.30-2.54)].

Conclusions

This study supports the idea that injection drug use is contributing to the increased spread of HIV among Iranian homeless. Harm reduction programs should be expanded, particularly among homeless injection drug users.     

Features associated with underlying HIV infection in severe acute childhood malnutrition: a cross sectional study

Introduction

Up to half of all children presenting to Nutrition Rehabilitation Units (NRUs) in Malawi with severe acute malnutrition (SAM) are infected with HIV. There are many-similarities in the clinical presentation of SAM and HIV. It is important to identify HIV infected children, in order to improve case management. This study aims to identify features suggestive of HIV in children with SAM.

Methods

All 1024 children admitted to the Blantyre NRU between July 2006 and March 2007 had demographic, anthropometric and clinical characteristics documented on admission. HIV status was known for 904 children, with 445 (43%) seropositive and 459 (45%) seronegative. Features associated with HIV were determined.

Results

Associations were found for the following signs: chronic ear discharge (OR 14.6, 95%CI 5.8–36.7), lymphadenopathy (6.4, 3.5–11.7), clubbing (4.9, 2.6–9.4), marasmus (4.9, 3.56.8), hepato-splenomegally (3.2, 1.8–5.6), and oral Candida (2.4, 1.8–3.27). Any one of these signs was present in 74% of the HIV seropositive, and 38% of HIV uninfected children. A history of recurrent respiratory infection (OR 9.6, 4.8–18.6), persistent fever, recent outpatient attendance, or hospital admission were also associated with HIV. Persistent diarrhoea was no more frequent in HIV (OR 1.1). Orphaning (OR 2.1,1.4–3.3) or a household contact with TB (OR 1.7,1.1–2.6), were more common in HIV. Each of these features were present in > 10% of seropositive children. HIV infected children were more stunted, wasted, and anaemic than uninfected children.

Conclusions

Features commonly associated with HIV were often present in uninfected children with SAM, and HIV could neither be diagnosed, nor excluded using these. We recommend HIV testing be offered to all children with SAM where HIV is prevalent.     

Research and applications: Leveraging biodiversity knowledge for potential phyto-therapeutic applications

Objective

To identify and highlight the feasibility, challenges, and advantages of providing a cross-domain pipeline that can link relevant biodiversity information for phyto-therapeutic assessment.

Materials and methods

A public repository of clinical trials information (ClinicalTrials.gov) was explored to determine the state of plant-based interventions under investigation.

Results

The results showed that ∼15% of drug interventions in ClinicalTrials.gov were potentially plant related, with about 60% of them clustered within 10 taxonomic families. Further analysis of these plant-based interventions identified ∼3.7% of associated plant species as endangered as determined from the International Union for the Conservation of Nature Red List.

Discussion

The diversity of the plant kingdom has provided human civilization with life-sustaining food and medicine for centuries. There has been renewed interest in the investigation of botanicals as sources of new drugs, building on traditional knowledge about plant-based medicines. However, data about the plant-based biodiversity potential for therapeutics (eg, based on genetic or chemical information) are generally scattered across a range of sources and isolated from contemporary pharmacological resources. This study explored the potential to bridge biodiversity and biomedical knowledge sources.

Conclusions

The findings from this feasibility study suggest that there is an opportunity for developing plant-based drugs and further highlight taxonomic relationships between plants that may be rich sources for bioprospecting.