ALBERT

Description: Background: The process of creating and designing Virtual Patients for teaching students of medicine is an expensive and time-consuming task. In order to explore potential methods of mitigating these costs, our group began exploring the possibility of creating Virtual Patients based on electronic health records. This review assesses the usage of electronic health records in the creation of interactive Virtual Patients for teaching clinical decision-making. Methods: The PubMed database was accessed programmatically to find papers relating to Virtual Patients. The returned citations were classified and the relevant full text articles were reviewed to find Virtual Patient systems that used electronic health records to create learning modalities. Results: A total of n = 362 citations were found on PubMed and subsequently classified, of which n = 28 full-text articles were reviewed. Few articles used unformatted electronic health records other than patient CT or MRI scans. The use of patient data, extracted from electronic health records or otherwise, is widespread. The use of unformatted electronic health records in their raw form is less frequent. Patient data use is broad and spans several areas, such as teaching, training, 3D visualisation, and assessment. Conclusions: Virtual Patients that are based on real patient data are widespread, yet the use of unformatted electronic health records, abundant in hospital information systems, is reported less often. The majority of teaching systems use reformatted patient data gathered from electronic health records, and do not use these electronic health records directly. Furthermore, many systems were found that used patient data in the form of CT or MRI scans. Much potential research exists regarding the use of unformatted electronic health records for the creation of Virtual Patients.

Description: Background: Human resources are an important building block of the health system. During the last decade, enormous investment has gone into the information systems to manage human resources, but due to the lack of a clear vision, policy, and strategy, the results of these efforts have not been very visible. No reliable information portal captures the actual state of human resources in Pakistan's health sector. The World Health Organization (WHO) has provided technical support for the assessment of the existing system and development of a comprehensive Human Resource Information System (HRIS) in Pakistan. Methods: The questions in the WHO-HRIS Assessment tool were distributed into five thematic groups. Purposively selected (n=65) representatives from the government, private sector, and development partners participated in this cross sectional study, based on their programmatic affiliations. Results: Fifty-five percent of organizations and departments have an independent Human Resources (HR) section managed by an establishment branch and are fully equipped with functional computers. Forty-five organizations (70%) had HR rules, regulations and coordination mechanisms, yet these are not implemented. Data reporting is mainly in paper form, on prescribed forms (51%), registers (3%) or even plain papers (20%). Data analysis does not give inputs to the decision making process and dissemination of information is quite erratic. Most of the organizations had no feedback mechanism for cross checking the HR data, rendering it unreliable. Conclusion: Pakistan is lacking appropriate HRIS management. The current HRIS indeed has a multitude of problems. In the wake of 2011 reforms within the health sector, provinces are even in a greater need for planning their respective health department services and must work on the deficiencies and inefficiencies of their HRIS so that the gaps and HR needs are better aligned for reaching the 2015 UN Millennium Development Goals (MDGs) targets.

Description: Background: Decision support systems for differential diagnosis have traditionally been evaluated on the basis of criteria how sensitively and specifically they are able to identify the correct diagnosis established by expert clinicians.DiscussionThis article questions whether evaluation criteria pertaining to identifying the correct diagnosis are most appropriate or useful. Instead it advocates evaluation of decision support systems for differential diagnosis based on the criterion of maximizing value of information.SummaryThis approach quantitatively and systematically integrates several important clinical management priorities, including avoiding serious diagnostic errors of omission and avoiding harmful or expensive tests.

Description: Background: Patient Data Management Systems (PDMS) support clinical documentation at the bedside and have demonstrated effects on completeness of patient charting and the time spent on documentation. These systems are costly and raise the question if such a major investment pays off. We tried to answer the following questions: How do costs and revenues of an intensive care unit develop before and after introduction of a PDMS? Can higher revenues be obtained with improved PDMS documentation? Can we present cost savings attributable to the PDMS? Methods: Retrospective analysis of cost and reimbursement data of a 25 bed Intensive Care Unit at a German University Hospital, three years before (2004--2006) and three years after (2007--2009) PDMS implementation. Results: Costs and revenues increased continuously over the years. The profit of the investigated ICU was fluctuating over the years and seemingly depending on other factors as well. We found a small increase in profit in the year after the introduction of the PDMS, but not in the following years. Profit per case peaked at 1039 [euro sign] in 2007, but dropped subsequently to 639 [euro sign] per case. We found no clear evidence for cost savings after the PDMS introduction. Our cautious calculation did not consider additional labour costs for IT staff needed for system maintenance. Conclusions: The introduction of a PDMS has probably minimal or no effect on reimbursement. In our case the observed increase in profit was too small to amortize the total investment for PDMS implementation.This may add some counterweight to the literature, where expectations for tools such as the PDMS can be quite unreasonable.

Description: Background: Clinical decision support (CDS) for electronic prescribing systems (computerized physician order entry) should help prescribers in the safe and rational use of medicines. However, the best ways to alert users to unsafe or irrational prescribing are uncertain. Specifically, CDS systems may generate too many alerts, producing unwelcome distractions for prescribers, or too few alerts running the risk of overlooking possible harms. Obtaining the right balance of alerting to adequately improve patient safety should be a priority. Methods: A workshop funded through the European Regional Development Fund was convened by the University Hospitals Birmingham NHS Foundation Trust to assess current knowledge on alerts in CDS and to reach a consensus on a future research agenda on this topic. Leading European researchers in CDS and alerts in electronic prescribing systems were invited to the workshop. Results: We identified important knowledge gaps and suggest research priorities including (1) the need to determine the optimal sensitivity and specificity of alerts; (2) whether adaptation to the environment or characteristics of the user may improve alerts; and (3) whether modifying the timing and number of alerts will lead to improvements. We have also discussed the challenges and benefits of using naturalistic or experimental studies in the evaluation of alerts and suggested appropriate outcome measures. Conclusions: We have identified critical problems in CDS, which should help to guide priorities in research to evaluate alerts. It is hoped that this will spark the next generation of novel research from which practical steps can be taken to implement changes to CDS systems that will ultimately reduce alert fatigue and improve the design of future systems.

Description: Background: Quality assessment and continuous quality feedback to the staff is crucial for safety and efficiency of teleconsultation and triage. This study evaluates whether it is feasible to use an already existing telephone triage protocol to assess the appropriateness of point-of-care and time-to-treat recommendations after teleconsultations. Methods: Based on electronic patient records, we retrospectively compared the point-of-care and time-to-treat recommendations of the paediatric telephone triage protocol with the actual recommendations of trained physicians for children with abdominal pain, following a teleconsultation. Results: In 59 of 96 cases (61%) these recommendations were congruent with the paediatric telephone protocol. Discrepancies were either of organizational nature, due to factors such as local referral policies or gatekeeping insurance models, or of medical origin, such as milder than usual symptoms or clear diagnosis of a minor ailment. Conclusions: A paediatric telephone triage protocol may be applicable in healthcare systems other than the one in which it has been developed, if triage rules are adapted to match the organisational aspects of the local healthcare system.

Description: Background: Physician notes routinely recorded during patient care represent a vast and underutilized resource for human disease studies on a population scale. Their use in research is primarily limited by the need to separate confidential patient information from clinical annotations, a process that is resource-intensive when performed manually. This study seeks to create an automated method for de-identifying physician notes that does not require large amounts of private information: in addition to training a model to recognize Protected Health Information (PHI) within private physician notes, we reverse the problem and train a model to recognize non-PHI words and phrases that appear in public medical texts. Methods: Public and private medical text sources were analyzed to distinguish common medical words and phrases from Protected Health Information. Patient identifiers are generally nouns and numbers that appear infrequently in medical literature. To quantify this relationship, term frequencies and part of speech tags were compared between journal publications and physician notes. Standard medical concepts and phrases were then examined across ten medical dictionaries. Lists and rules were included from the US census database and previously published studies. In total, 28 features were used to train decision tree classifiers. Results: The model successfully recalled 98% of PHI tokens from 220 discharge summaries. Cost sensitive classification was used to weight recall over precision (98% F10 score, 76% F1 score). More than half of the false negatives were the word "of" appearing in a hospital name. All patient names, phone numbers, and home addresses were at least partially redacted. Medical concepts such as "elevated white blood cell count" were informative for de-identification. The results exceed the previously approved criteria established by four Institutional Review Boards. Conclusions: The results indicate that distributional differences between private and public medical text can be used to accurately classify PHI. The data and algorithms reported here are made freely available for evaluation and improvement.

Description: Background: As adolescents with hemophilia approach adulthood, they are expected to assume responsibility for their disease management. A bilingual (English and French) Internet-based self-management program, "Teens Taking Charge: Managing Hemophilia Online," was developed to support adolescents with hemophilia in this transition. This study explored the usability of the website and resulted in refinement of the prototype. Methods: A purposive sample (n=18; age 13--18; mean age 15.5 years) was recruited from two tertiary care centers to assess the usability of the program in English and French. Qualitative observations using a "think aloud" usability testing method and semi-structured interviews were conducted in four iterative cycles, with changes to the prototype made as necessary following each cycle. This study was approved by research ethics boards at each site. Results: Teens responded positively to the content and appearance of the website and felt that it was easy to navigate and understand. The multimedia components (videos, animations, quizzes) were felt to enrich the experience. Changes to the presentation of content and the website user-interface were made after the first, second and third cycles of testing in English. Cycle four did not result in any further changes. Conclusions: Overall, teens found the website to be easy to use. Usability testing identified end-user concerns that informed improvements to the program. Usability testing is a crucial step in the development of Internet-based self-management programs to ensure information is delivered in a manner that is accessible and understood by users.

Description: Background: Within the field of record linkage, numerous data cleaning and standardisation techniques are employed to ensure the highest quality of links. While these facilities are common in record linkage software packages and are regularly deployed across record linkage units, little work has been published demonstrating the impact of data cleaning on linkage quality. Methods: A range of cleaning techniques was applied to both a synthetically generated dataset and a large administrative dataset previously linked to a high standard. The effect of these changes on linkage quality was investigated using pairwise F-measure to determine quality. Results: Data cleaning made little difference to the overall linkage quality, with heavy cleaning leading to a decrease in quality. Further examination showed that decreases in linkage quality were due to cleaning techniques typically reducing the variability -- although correct records were now more likely to match, incorrect records were also more likely to match, and these incorrect matches outweighed the correct matches, reducing quality overall. Conclusion: Data cleaning techniques have minimal effect on linkage quality. Care should be taken during the data cleaning process.

Description: Background: Algorithms to identify screening colonoscopies in administrative databases would be useful for monitoring CRC screening uptake, tracking health resource utilization, and quality assurance. Previously developed algorithms based on expert opinion were insufficiently accurate. The purpose of this study was to develop and evaluate the accuracy of model-based algorithms to identify screening colonoscopies in health administrative databases. Methods: Patients aged 50-75 were recruited from endoscopy units in Montreal, Quebec, and Calgary, Alberta. Physician billing records and hospitalization data were obtained for each patient from the provincial administrative health databases. Indication for colonoscopy was derived using Bayesian latent class analysis informed by endoscopist and patient questionnaire responses. Two modeling methods were used to fit the data, multivariate logistic regression and recursive partitioning. The accuracies of these models were assessed. Results: 689 patients from Montreal and 541 from Calgary participated (January to March 2007). The latent class model identified 554 screening exams. Multivariate logistic regression predictions yielded an area under the curve of 0.786. Recursive partitioning using the latent outcome had sensitivity and specificity of 84.5% (95% CI: 81.5-87.5) and 63.3% (95% CI: 59.7-67.0), respectively. Conclusions: Model-based algorithms using administrative data failed to identify screening colonoscopies with sufficient accuracy. Nevertheless, the approach of constructing a latent reference standard against which model-based algorithms were evaluated may be useful for validating administrative data in other contexts where there lacks a gold standard.

Description: Background: Blindness due to diabetic retinopathy (DR) is the major disability in diabetic patients. Although early management has shown to prevent vision loss, diabetic patients have a low rate of routine ophthalmologic examination. Hence, we developed and validated sparse learning models with the aim of identifying the risk of DR in diabetic patients. Methods: Health records from the Korea National Health and Nutrition Examination Surveys (KNHANES) V-1 were used. The prediction models for DR were constructed using data from 327 diabetic patients, and were validated internally on 163 patients in the KNHANES V-1. External validation was performed using 562 diabetic patients in the KNHANES V-2. The learning models, including ridge, elastic net, and LASSO, were compared to the traditional indicators of DR. Results: Considering the Bayesian information criterion, LASSO predicted DR most efficiently. In the internal and external validation, LASSO was significantly superior to the traditional indicators by calculating the area under the curve (AUC) of the receiver operating characteristic. LASSO showed an AUC of 0.81 and an accuracy of 73.6% in the internal validation, and an AUC of 0.82 and an accuracy of 75.2% in the external validation. Conclusion: The sparse learning model using LASSO was effective in analyzing the epidemiological underlying patterns of DR. This is the first study to develop a machine learning model to predict DR risk using health records. LASSO can be an excellent choice when both discriminative power and variable selection are important in the analysis of high-dimensional electronic health records.

Description: Background: Paper-based Aboriginal and Torres Strait Islander health checks have promoted a preventive approach to primary care and provided data to support research at the Inala Indigenous Health Service, south-west Brisbane, Australia. Concerns about the limitations of paper-based health checks prompted us to change to a computerised system to realise potential benefits for clinical services and research capability. We describe the rationale, implementation and anticipated benefits of computerised Aboriginal and Torres Strait Islander health checks in one primary health care setting. Methods: In May 2010, the Inala Indigenous Health Service commenced a project to computerise Aboriginal and Torres Strait Islander child, adult, diabetic, and antenatal health checks. The computerised health checks were launched in September 2010 and then evaluated for staff satisfaction, research consent rate and uptake. Ethical approval for health check data to be used for research purposes was granted in December 2010. Results: Three months after the September 2010 launch date, all but two health checks (378 out of 380, 99.5%) had been completed using the computerised system. Staff gave the system a median mark of 8 out of 10 (range 5-9), where 10 represented the highest level of overall satisfaction. By September 2011, 1099 child and adult health checks, 138 annual diabetic checks and 52 of the newly introduced antenatal checks had been completed. These numbers of computerised health checks are greater than for the previous year (2010) of paper-based health checks with a risk difference of 0.07 (95% confidence interval 0.05, 0.10). Additionally, two research projects based on computerised health check data were underway. Conclusions: The Inala Indigenous Health Service has demonstrated that moving from paper-based Aboriginal and Torres Strait Islander health checks to a system using computerised health checks is feasible and can facilitate research. We expect computerised health checks will improve clinical care and continue to enable research projects using validated data, reflecting the local Aboriginal and Torres Strait Islander community's priorities.

Description: Background: With the increasing prevalence of Picture Archiving and Communication Systems (PACS) in healthcare institutions, there is a growing need to measure their success. However, there is a lack of published literature emphasizing the technical and social factors underlying a successful PACS. Methods: An updated Information Systems Success Model was utilized by radiology technologists (RTs) to evaluate the success of PACS at a large medical center in Taiwan. A survey, consisting of 109 questionnaires, was analyzed by Structural Equation Modeling. Results: Socio-technical factors (including system quality, information quality, service quality, perceived usefulness, user satisfaction, and PACS dependence) were proven to be effective measures of PACS success. Although the relationship between service quality and perceived usefulness was not significant, other proposed relationships amongst the six measurement parameters of success were all confirmed. Conclusions: Managers have an obligation to improve the attributes of PACS. At the onset of its deployment, RTs will have formed their own subjective opinions with regards to its quality (system quality, information quality, and service quality). As these personal concepts are either refuted or reinforced based on personal experiences, RTs will become either satisfied or dissatisfied with PACS, based on their perception of its usefulness or lack of usefulness. A satisfied RT may play a pivotal role in the implementation of PACS in the future.

Description: Background: For selection and evaluation of potential biomarkers, inclusion of already published information is of utmost importance. In spite of significant advancements in text- and data-mining techniques, the vast knowledge space of biomarkers in biomedical text has remained unexplored. Existing named entity recognition approaches are not sufficiently selective for the retrieval of biomarker information from the literature. The purpose of this study was to identify textual features that enhance the effectiveness of biomarker information retrieval for different indication areas and diverse end user perspectives. Methods: A biomarker terminology was created and further organized into six concept classes. Performance of this terminology was optimized towards balanced selectivity and specificity. The information retrieval performance using the biomarker terminology was evaluated based on various combinations of the terminology's six classes. Further validation of these results was performed on two independent corpora representing two different neurodegenerative diseases. Results: The current state of the biomarker terminology contains 119 entity classes supported by 1890 different synonyms. The result of information retrieval shows improved retrieval rate of informative abstracts, which is achieved by including clinical management terms and evidence of gene/protein alterations (e.g. gene/protein expression status or certain polymorphisms) in combination with disease and gene name recognition. When additional filtering through other classes (e.g. diagnostic or prognostic methods) is applied, the typical high number of unspecific search results is significantly reduced. The evaluation results suggest that this approach enables the automated identification of biomarker information in the literature. A demo version of the search engine SCAIView, including the biomarker retrieval, is made available to the public through http://www.scaiview.com/scaiview-academia.html. Conclusions: The approach presented in this paper demonstrates that using a dedicated biomarker terminology for automated analysis of the scientific literature maybe helpful as an aid to finding biomarker information in text. Successful extraction of candidate biomarkers information from published resources can be considered as the first step towards developing novel hypotheses. These hypotheses will be valuable for the early decision-making in the drug discovery and development process.

Description: Background: There has been increasing emphasis on evidence-based approaches to improve patient outcomes through rigorous, standardised and well- validated approaches. Clinical guidelines drive this process and are largely developed based on the findings of systematic reviews (SRs). This paper presents a discussion of the SR process in providing decisive information to shape and guide clinical practice, using a purpose-built review database: the Cochrane reviews; and focussing on a highly prevalent medical condition: hypertension. Methods: We searched the Cochrane database and identified 25 relevant SRs incorporating 443 clinical trials. Reviews with the terms 'blood pressure' or 'hypertension' in the title were included. Once selected for inclusion, the abstracts were assessed independently by two authors for their capacity to inform and influence clinical decision-making. The inclusions were independently audited by a third author. Results: Of the 25 SRs that formed the sample, 12 provided conclusive findings to inform a particular treatment pathway. The evidence-based approaches offer the promise of assisting clinical decision-making through clarity, but in the case of management of blood pressure, half of the SRs in our sample highlight gaps in evidence and methodological limitations. Thirteen reviews were inconclusive, and eight, including four of the 12 conclusive SRs, noted the lack of adequate reporting of potential adverse effects or incidence of harm. Conclusions: These findings emphasise the importance of distillation, interpretation and synthesis of information to assist clinicians. This study questions the utility of evidence-based approaches as a uni-dimensional approach to improving clinical care and underscores the importance of standardised approaches to include adverse events, incidence of harm, patient's needs and preferences and clinician's expertise and discretion.

Description: Background: To reduce the large public health burden of the high prevalence of depression, preventive interventions targeted at people at risk are essential and can be cost-effective. Web-based interventions are able to provide this care, but there is no agreement on how to best develop these applications and often the technology is seen as a given. This seems to be one of the main reasons that web-based interventions do not reach their full potential. The current study describes the development of a web-based intervention for the indicated prevention of depression, employing the CeHRes (Center for eHealth Research and Disease Management) roadmap. The goals are to create a user-friendly application which fits the values of the stakeholders and to evaluate the process of development. Methods: The employed methods are a literature scan and discussion in the contextual inquiry; interviews, rapid prototyping and a requirement session in the value specification stage; and user-based usability evaluation, expert-based usability inspection and a requirement session in the design stage. Results: The contextual inquiry indicated that there is a need for easily accessible interventions for the indicated prevention of depression and web-based interventions are seen as potentially meeting this need. The value specification stage yielded expected needs of potential participants, comments on the usefulness of the proposed features and comments on two proposed designs of the web-based intervention. The design stage yielded valuable comments on the system, content and service of the web-based intervention. Conclusions: Overall, we found that by developing the technology, we successfully (re)designed the system, content and service of the web-based intervention to match the values of stakeholders. This study has shown the importance of a structured development process of a web-based intervention for the indicated prevention of depression because: (1) it allows the development team to clarify the needs that have to be met for the intervention to be of use to the target audience; and (2) it yields feedback on the design of the application that is broader than color and buttons, but encompasses comments on the quality of the service that the application offers.

Description: Background: Patient-reported Outcomes (PROs) capturing e.g., quality of life, fatigue, depression, medication side-effects or disease symptoms, have become important outcome parameters in medical research and daily clinical practice. Electronic PRO data capture (ePRO) with software packages to administer questionnaires, storing data, and presenting results has facilitated PRO assessment in hospital settings. Compared to conventional paper-pencil versions of PRO instruments, ePRO is more economical with regard to staff resources and time, and allows immediate presentation of results to the medical staff.The objective of our project was to develop software (CHES -- Computer-based Health Evaluation System) for ePRO in hospital settings and at home with a special focus on the presentation of individual patient's results. Methods: Following the Extreme Programming development approach architecture was not fixed up-front, but was done in close, continuous collaboration with software end users (medical staff, researchers and patients) to meet their specific demands. Developed features include sophisticated, longitudinal charts linking patients' PRO data to clinical characteristics and to PRO scores from reference populations, a web-interface for questionnaire administration, and a tool for convenient creating and editing of questionnaires. Results: By 2012 CHES has been implemented at various institutions in Austria, Germany, Switzerland, and the UK and about 5000 patients participated in ePRO (with around 15000 assessments in total). Data entry is done by the patients themselves via tablet PCs with a study nurse or an intern approaching patients and supervising questionnaire completion.DiscussionDuring the last decade several software packages for ePRO have emerged for different purposes. Whereas commercial products are available primarily for ePRO in clinical trials, academic projects have focused on data collection and presentation in daily clinical practice and on extending cancer registries with PRO data. CHES includes several features facilitating the use of PRO data for individualized medical decision making. With its web-interface it allows ePRO also when patients are home. Thus, it provides complete monitoring of patients'physical and psychosocial symptom burden.

Description: Background: The problem list is a key part of the electronic health record (EHR) that allows practitioners to see a patient's diagnoses and health issues. Yet, as the content of the problem list largely represents the subjective decisions of those who edit it, patients' problem lists are often unreliable when shared across practitioners. The lack of standards for how the problem list is compiled in the EHR limits its effectiveness in improving patient care, particularly as a resource for clinical decision support and population management tools. The purpose of this study is to discover practitioner opinions towards the problem list and the logic behind their decisions during clinical situations.Materials and methodsAn observational cross-sectional study was conducted at two major Boston teaching hospitals. Practitioners' opinions about the problem list were collected through both in-person interviews and an online questionnaire. Questions were framed using vignettes of clinical scenarios asking practitioners about their preferred actions towards the problem list. Results: These data confirmed prior research that practitioners differ in their opinions over managing the problem list, but in most responses to a questionnaire, there was a common approach among the relative majority of respondents. Further, basic demographic characteristics of providers (age, medical experience, etc.) did not appear to strongly affect attitudes towards the problem list. Conclusion: The results supported the premise that policies and EHR tools are needed to bring about a common approach. Further, the findings helped identify what issues might benefit the most from a defined policy and the level of restriction a problem list policy should place on the addition of different types of information.

Description: Background: Professional societies recommend shared decision making (SDM) for prostate cancer screening, however, most efforts have promoted informed rather than shared decision making. The objective of this study is to 1) examine the effects of a prostate cancer screening intervention to promote SDM and 2) determine whether framing prostate information in the context of other clearly beneficial men's health services affects decisions. Methods: We conducted two separate randomized controlled trials of the same prostate cancer intervention (with or without additional information on more clearly beneficial men's health services). For each trial, we enrolled a convenience sample of 2 internal medicine practices, and their interested physicians and male patients with no prior history of prostate cancer (for a total of 4 practices, 28 physicians, and 128 men across trials). Within each practice site, we randomized men to either 1) a video-based decision aid and researcher-led coaching session or 2) a highway safety video. Physicians at each site received a 1-hour educational session on prostate cancer and SDM. To assess intervention effects, we measured key components of SDM, intent to be screened, and actual screening. After finding that results did not vary by trial, we combined data across sites, adjusting for the random effects of both practice and physician. Results: Compared to an attention control, our prostate cancer screening intervention increased men's perceptions that screening is a decision (absolute difference +41%; 95% CI 25 to 57%) and men's knowledge about prostate cancer screening (absolute difference +34%; 95% CI 19% to 50%), but had no effect on men's self-reported participation in shared decisions or their participation at their preferred level. Overall, the intervention decreased screening intent (absolute difference -34%; 95% CI -50% to -18%) and actual screening rates (absolute difference -22%; 95% CI -38 to -7%) with no difference in effect by frame. Conclusions: SDM interventions can increase men's knowledge, alter their perceptions of prostate cancer screening, and reduce actual screening. However, they may not guarantee an increase in shared decisions.Trial registration#NCT00630188

Description: Background: Efficient rule authoring tools are critical to allow clinical Knowledge Engineers (KEs), Software Engineers (SEs), and Subject Matter Experts (SMEs) to convert medical knowledge into machine executable clinical decision support rules. The goal of this analysis was to identify the critical success factors and challenges of a fully functioning Rule Authoring Environment (RAE) in order to define requirements for a scalable, comprehensive tool to manage enterprise level rules. Methods: The authors evaluated RAEs in active use across Partners Healthcare, including enterprise wide, ambulatory only, and system specific tools, with a focus on rule editors for reminder and medication rules. We conducted meetings with users of these RAEs to discuss their general experience and perceived advantages and limitations of these tools. Results: While the overall rule authoring process is similar across the 10 separate RAEs, the system capabilities and architecture vary widely. Most current RAEs limit the ability of the clinical decision support (CDS) interventions to be standardized, sharable, interoperable, and extensible. No existing system meets all requirements defined by knowledge management users. Conclusions: A successful, scalable, integrated rule authoring environment will need to support a number of key requirements and functions in the areas of knowledge representation, metadata, terminology, authoring collaboration, user interface, integration with electronic health record (EHR) systems, testing, and reporting.

Description: Background: Hyperbilirubinemia is emerging as an increasingly common problem in newborns due to a decreasing hospital length of stay after birth. Jaundice is the most common disease of the newborn and although being benign in most cases it can lead to severe neurological consequences if poorly evaluated. In different areas of medicine, data mining has contributed to improve the results obtained with other methodologies.Hence, the aim of this study was to improve the diagnosis of neonatal jaundice with the application of data mining techniques. Methods: This study followed the different phases of the Cross Industry Standard Process for Data Mining model as its methodology.This observational study was performed at the Obstetrics Department of a central hospital (Centro Hospitalar Tamega e Sousa -- EPE), from February to March of 2011. A total of 227 healthy newborn infants with 35 or more weeks of gestation were enrolled in the study. Over 70 variables were collected and analyzed. Also, transcutaneous bilirubin levels were measured from birth to hospital discharge with maximum time intervals of 8 hours between measurements, using a noninvasive bilirubinometer.Different attribute subsets were used to train and test classification models using algorithms included in Weka data mining software, such as decision trees (J48) and neural networks (multilayer perceptron). The accuracy results were compared with the traditional methods for prediction of hyperbilirubinemia. Results: The application of different classification algorithms to the collected data allowed predicting subsequent hyperbilirubinemia with high accuracy. In particular, at 24 hours of life of newborns, the accuracy for the prediction of hyperbilirubinemia was 89%. The best results were obtained using the following algorithms: naive Bayes, multilayer perceptron and simple logistic. Conclusions: The findings of our study sustain that, new approaches, such as data mining, may support medical decision, contributing to improve diagnosis in neonatal jaundice.

Description: Background: The quantum increases in home Internet access and available online health information with limited control over information quality highlight the necessity of exploring decision making processes in accessing and using online information, specifically in relation to children who do not make their health decisions. The aim of this study was to understand the processes explaining parents' decisions to use online health information for child health care. Methods: Parents (N = 391) completed an initial questionnaire assessing the theory of planned behaviour constructs of attitude, subjective norm, and perceived behavioural control, as well as perceived risk, group norm, and additional demographic factors. Two months later, 187 parents completed a follow-up questionnaire assessing their decisions to use online information for their child's health care, specifically to 1) diagnose and/or treat their child's suspected medical condition/illness and 2) increase understanding about a diagnosis or treatment recommended by a health professional. Results: Hierarchical multiple regression showed that, for both behaviours, attitude, subjective norm, perceived behavioural control, (less) perceived risk, group norm, and (non) medical background were the significant predictors of intention. For parents' use of online child health information, for both behaviours, intention was the sole significant predictor of behaviour. The findings explain 77% of the variance in parents' intention to treat/diagnose a child health problem and 74% of the variance in their intentions to increase their understanding about child health concerns. Conclusions: Understanding parents' socio-cognitive processes that guide their use of online information for child health care is important given the increase in Internet usage and the sometimes-questionable quality of health information provided online. Findings highlight parents' thirst for information; there is an urgent need for health professionals to provide parents with evidence-based child health websites in addition to general population education on how to evaluate the quality of online health information.

Description: Background: Evidence informed decision making in health policy development and clinical practice depends on the availability of valid and reliable data. The introduction of interRAI assessment systems in many countries has provided valuable new information that can be used to support case mix based payment systems, quality monitoring, outcome measurement and care planning. The Continuing Care Reporting System (CCRS) managed by the Canadian Institute for Health Information has served as a data repository supporting national implementation of the Resident Assessment Instrument (RAI 2.0) in Canada for more than 15 years. The present paper aims to evaluate data quality for the CCRS using an approach that may be generalizable to comparable data holdings internationally. Methods: Data from the RAI 2.0 implementation in Complex Continuing Care (CCC) hospitals/units and Long Term Care (LTC) homes in Ontario were analyzed using various statistical techniques that provide evidence for trends in validity, reliability, and population attributes. Time series comparisons included evaluations of scale reliability, patterns of associations between items and scales that provide evidence about convergent validity, and measures of changes in population characteristics over time. Results: Data quality with respect to reliability, validity, completeness and freedom from logical coding errors was consistently high for the CCRS in both CCC and LTC settings. The addition of logic checks further improved data quality in both settings. The only notable change of concern was a substantial inflation in the percentage of long term care home residents qualifying for the Special Rehabilitation level of the Resource Utilization Groups (RUG-III) case mix system after the adoption of that system as part of the payment system for LTC. Conclusions: The CCRS provides a robust, high quality data source that may be used to inform policy, clinical practice and service delivery in Ontario. Only one area of concern was noted, and the statistical techniques employed here may be readily used to target organizations with data quality problems in that (or any other) area. There was also evidence that data quality was good in both CCC and LTC settings from the outset of implementation, meaning data may be used from the entire time series. The methods employed here may continue to be used to monitor data quality in this province over time and they provide a benchmark for comparisons with other jurisdictions implementing the RAI 2.0 in similar populations.

Description: Background: Distinguishing cases from non-cases in free-text electronic medical records is an important initial step in observational epidemiological studies, but manual record validation is time-consuming and cumbersome. We compared different approaches to develop an automatic case identification system with high sensitivity to assist manual annotators. Methods: We used four different machine-learning algorithms to build case identification systems for two data sets, one comprising hepatobiliary disease patients, the other acute renal failure patients. To improve the sensitivity of the systems, we varied the imbalance ratio between positive cases and negative cases using under- and over-sampling techniques, and applied cost-sensitive learning with various misclassification costs. Results: For the hepatobiliary data set, we obtained a high sensitivity of 0.95 (on a par with manual annotators, as compared to 0.91 for a baseline classifier) with specificity 0.56. For the acute renal failure data set, sensitivity increased from 0.69 to 0.89, with specificity 0.59. Performance differences between the various machine-learning algorithms were not large. Classifiers performed best when trained on data sets with imbalance ratio below 10. Conclusions: We were able to achieve high sensitivity with moderate specificity for automatic case identification on two data sets of electronic medical records. Such a high-sensitive case identification system can be used as a pre-filter to significantly reduce the burden of manual record validation.

Description: Background: One possible approach towards avoiding alert overload and alert fatigue in Computerized Physician Order Entry (CPOE) systems is to tailor their drug safety alerts to the context of the clinical situation. Our objective was to identify the perceptions of physicians on the usefulness of clinical context information for prioritizing and presenting drug safety alerts. Methods: We performed a questionnaire survey, inquiring CPOE-using physicians from four hospitals in four European countries to estimate the usefulness of 20 possible context factors. Results: The 223 participants identified the 'severity of the effect' and the 'clinical status of the patient' as the most useful context factors. Further important factors are the 'complexity of the case' and the 'risk factors of the patient'. Conclusions: Our findings confirm the results of a prior, comparable survey inquiring CPOE researchers. Further research should focus on implementing these context factors in CPOE systems and on subsequently evaluating their impact.

Description: Background: Information is essential in healthcare. Recording, handling and sharing healthcare information is important in order to ensure high quality of delivered healthcare. Information and communication technology (ICT) may be a valuable tool for handling these challenges. One way of enhancing the exchange of information could be to establish a link between patient-specific and general information sent to the general practitioner (GP). The aim of the present paper is to study GPs' use of a hyperlink inserted into electronic test result communication. Methods: We inserted a hyperlink into the electronic test result communication sent to the patients' GPs who participated in a regional, systematic breast cancer screening program. The hyperlink target was a web-site with information on the breast cancer screening program and breast cancer in general. Different strategies were used to increase the GPs' use of this hyperlink. The outcome measure was the GPs' self-reported use of the link. Data were collected by means of a one-page paper-based questionnaire. Results: The response rate was 73% (n=242). In total, 108 (45%) of the GPs reported to have used the link. In all, 22% (n=53) of the GPs used the web-address from a paper letter and 37% (n=89) used the hyperlink in the electronic test result communication (Delta = 15%[95%confidence int erval(CI) = 8 - 22%P 〈 0.001]). We found no statistically significant associations between use of the web-address/hyperlink and the GP's gender, age, or attitude towards mammography screening. Conclusions: The results suggest that hyperlinks in electronic test result communication could be a feasible strategy for combining and sharing different types of healthcare information.

Description: Background: Recently, there has been considerable effort to promote the use of health informationtechnology (HIT) in order to improve health care quality. However, relatively little is knownabout the extent to which HIT implementation is associated with hospital patient care quality.We undertook this study to determine the association of various HITs with: hospital qualityimprovement (QI) practices and strategies; adherence to process of care measures; riskadjustedinpatient mortality; patient satisfaction; and assessment of patient care quality byhospital quality managers and front-line clinicians. Methods: We conducted surveys of quality managers and front-line clinicians (physicians and nurses)in 470 short-term, general hospitals to obtain data on hospitals' extent of HITimplementation, QI practices and strategies, assessments of quality performance,commitment to quality, and sufficiency of resources for QI. Of the 470 hospitals, 401submitted complete data necessary for analysis. We also developed measures of hospitalperformance from several publicly data available sources: Hospital Compare adherence toprocess of care measures; Medicare Provider Analysis and Review (MEDPAR) file; andHospital Consumer Assessment of Healthcare Providers and Systems HCAHPS(R) survey. Weused Poisson regression analysis to examine the association between HIT implementation andQI practices and strategies, and general linear models to examine the relationship betweenHIT implementation and hospital performance measures. Results: Controlling for potential confounders, we found that hospitals with high levels of HITimplementation engaged in a statistically significant greater number of QI practices andstrategies, and had significantly better performance on mortality rates, patient satisfactionmeasures, and assessments of patient care quality by hospital quality managers; there wasweaker evidence of higher assessments of patient care quality by front-line clinicians. Conclusions: Hospital implementation of HIT was positively associated with activities intended to improvepatient care quality and with higher performance on four of six performance measures.

Description: Background: Influenza is a well known and common human respiratory infection, causing significant morbidity and mortality every year. Despite Influenza variability, fast and reliable outbreak detection is required for health resource planning. Clinical health records, as published by the Diagnosticat database in Catalonia, host useful data for probabilistic detection of influenza outbreaks. Methods: This paper proposes a statistical method to detect influenza epidemic activity. Non-epidemic incidence rates are modeled against the exponential distribution, and the maximum likelihood estimate for the decaying factor $\lambda$ is calculated. The sequential detection algorithm updates the parameter as new data becomes available. Binary epidemic detection of weekly incidence rates is assessed by Kolmogorov-Smirnov test on the absolute difference between the empirical and the cumulative density function of the estimated exponential distribution with significance level $0\leq \alpha \leq 1$. Results: The main advantage with respect to other approaches is the adoption of a statistically meaningful test, which provides an indicator of epidemic activity with an associated probability. The detection algorithm was initiated with parameter $\lambda_0= 3.8617$ estimated from the training sequence (corresponding to non-epidemic rates of the 2008-2009 influenza season) and sequentially updated. Kolmogorov-Smirnov test detected the following weeks as epidemic for each influenza season: 50-10 (2008-2009 season), 38-50 (2009-2010 season), weeks 50-9 (2010-2011 season) and weeks 3 to 12 for the current 2011-2012 season. Conclusions: Real medical data was used to assess the validity of the approach, as well as to construct a realistic statistical model of weekly influenza incidence rates in non-epidemic periods. For the tested data, the results confirmed the ability of the algorithm to detect the start and the end of epidemic periods. In general, the proposed test could be applied to other data sets to quickly detect influenza outbreaks. The sequential structure of the test makes it suitable for implementation in many platforms at a low computational cost without requiring to store large data sets.

Description: Background: Misplaced or poorly calibrated confidence in healthcare professionals' judgments compromises the quality of health care. Using higher fidelity clinical simulations to elicit clinicians' confidence 'calibration' (i.e. overconfidence or underconfidence) in more realistic settings is a promising but underutilized tactic. In this study we examine nurses' calibration of confidence with judgment accuracy for critical event risk assessment judgments in a high fidelity simulated clinical environment. The study also explores the effects of clinical experience, task difficulty and time pressure on the relationship between confidence and accuracy. Methods: 63 student and 34 experienced nurses made dichotomous risk assessments on 25 scenarios simulated in a high fidelity clinical environment. Each nurse also assigned a score (0--100) reflecting the level of confidence in their judgments. Scenarios were derived from real patient cases and classified as easy or difficult judgment tasks. Nurses made half of their judgments under time pressure. Confidence calibration statistics were calculated and calibration curves generated. Results: Nurse students were underconfident (mean over/underconfidence score -1.05) and experienced nurses overconfident (mean over/underconfidence score 6.56), P = 0.01. No significant differences in calibration and resolution were found between the two groups (P = 0.80 and P = 0.51, respectively). There was a significant interaction between time pressure and task difficulty on confidence (P = 0.008); time pressure increased confidence in easy cases but reduced confidence in difficult cases. Time pressure had no effect on confidence or accuracy. Judgment task difficulty impacted significantly on nurses' judgmental accuracy and confidence. A 'hard-easy' effect was observed: nurses were overconfident in difficult judgments and underconfident in easy judgments. Conclusion: Nurses were poorly calibrated when making risk assessment judgments in a high fidelity simulated setting. Nurses with more experience tended toward overconfidence. Whilst time pressure had little effect on calibration, nurses' over/underconfidence varied significantly with the degree of task difficulty. More research is required to identify strategies to minimize such cognitive biases.

Description: Background: Functional brain images such as Single-Photon Emission Computed Tomography (SPECT) and PositronEmission Tomography (PET) have been widely used to guide the clinicians in the Alzheimer's Disease (AD)diagnosis. However, the subjectivity involved in their evaluation has favoured the development of ComputerAided Diagnosis (CAD) Systems. Methods: It is proposed a novel combination of feature extraction techniques to improve the diagnosis of AD. Firstly,Regions of Interest (ROIs) are selected by means of a t-test carried out on 3D Normalised Mean SquareError (NMSE) features restricted to be located within a predefined brain activation mask. In order to addressthe small sample-size problem, the dimension of the feature space was further reduced by: Large MarginNearest Neighbours using a rectangular matrix (LMNN-RECT), Principal Component Analysis (PCA) orPartial Least Squares (PLS) (the two latter also analysed with a LMNN transformation). Regarding theclassifiers, kernel Support Vector Machines (SVMs) and LMNN using Euclidean, Mahalanobis andEnergy-based metrics were compared. Results: Several experiments were conducted in order to evaluate the proposed LMNN-based feature extractionalgorithms and its benefits as: i) linear transformation of the PLS or PCA reduced data, ii) feature reductiontechnique, and iii) classifier (with Euclidean, Mahalanobis or Energy-based methodology). The system wasevaluated by means of k-fold cross-validation yielding accuracy, sensitivity and specificity values of92.78%, 91.07% and 95.12% (for SPECT) and 90.67%, 88% and 93.33% (for PET), respectively, when aNMSE-PLS-LMNN feature extraction method was used in combination with a SVM classifier, thusoutperforming recently reported baseline methods. Conclusions: All the proposed methods turned out to be a valid solution for the presented problem. One of the advances isthe robustness of the LMNN algorithm that not only provides higher separation rate between the classes butit also makes (in combination with NMSE and PLS) this rate variation more stable. In addition, theirgeneralization ability is another advance since several experiments were performed on two image modalities(SPECT and PET).

Description: Background: Semantic Web technology can considerably catalyze translational genetics and genomicsresearch in medicine, where the interchange of information between basic research andclinical levels becomes crucial. This exchange involves mapping abstract phenotypedescriptions from research resources, such as knowledge databases and catalogs, tounstructured datasets produced through experimental methods and clinical practice. This isespecially true for the construction of mutation databases. This paper presents a way ofharmonizing abstract phenotype descriptions with patient data from clinical practice, andquerying this dataset about relationships between phenotypes and genetic variants, atdifferent levels of abstraction. Methods: Due to the current availability of ontological and terminological resources that have alreadyreached some consensus in biomedicine, a reuse-based ontology engineering approach wasfollowed. The proposed approach uses the Ontology Web Language (OWL) to represent thephenotype ontology and the patient model, the Semantic Web Rule Language (SWRL) tobridge the gap between phenotype descriptions and clinical data, and the Semantic QueryWeb Rule Language (SQWRL) to query relevant phenotype-genotype bidirectionalrelationships. The work tests the use of semantic web technology in the biomedical researchdomain named cerebrotendinous xanthomatosis (CTX), using a real dataset and ontologies. Results: A framework to query relevant phenotype-genotype bidirectional relationships is provided.Phenotype descriptions and patient data were harmonized by defining 28 Horn-like rules interms of the OWL concepts. In total, 24 patterns of SWQRL queries were designed followingthe initial list of competency questions. As the approach is based on OWL, the semantic ofthe framework adapts the standard logical model of an open world assumption. Conclusions: This work demonstrates how semantic web technologies can be used to support flexiblerepresentation and computational inference mechanisms required to query patient datasets atdifferent levels of abstraction. The open world assumption is especially good for describingonly partially known phenotype-genotype relationships, in a way that is easily extensible. Infuture, this type of approach could offer researchers a valuable resource to infer new datafrom patient data for statistical analysis in translational research. In conclusion, phenotypedescription formalization and mapping to clinical data are two key elements for interchangingknowledge between basic and clinical research.

Description: Background: Lifestyle-related diseases represented by metabolic syndrome develop as results of complex interaction. By using health check-up data from two large studies collected during a long-term follow-up, we searched for risk factors associated with the development of metabolic syndrome. Methods: In our original study, we selected 77 case subjects who developed metabolic syndrome during the follow-up and 152 healthy control subjects who were free of lifestyle-related risk components from among 1803 Japanese male employees. In a replication study, we selected 2196 case subjects and 2196 control subjects from among 31343 other Japanese male employees. By means of a bioinformatics approach using a fuzzy neural network (FNN), we searched any significant combinations that are associated with MetS. To ensure that the risk combination selected by FNN analysis was statistically reliable, we performed logistic regression analysis including adjustment. Results: We selected a combination of an elevated level of gamma-glutamyltranspeptidase (gamma-GTP, GGTP) and an elevated white blood cell (WBC) count as the most significant combination of risk factors for the development of metabolic syndrome. The FNN also identified the same tendency in a replication study. The clinical characteristics of gamma-GTP level and WBC count were statistically significant even after adjustment, confirming that the results obtained from the fuzzy neural network are reasonable. Correlation ratio showed that an elevated level of gamma-GTP is associated with habitual drinking of alcohol and a high WBC count is associated with habitual smoking. Conclusions: This result obtained by fuzzy neural network analysis of health check-up data from large long-term studies can be useful in providing a personalized novel diagnostic and therapeutic method involving the gamma-GTP level and the WBC count.

Description: Background: Primary health care in industrialized countries faces major challenges due to demographic changes, an increasing prevalence of chronic diseases and a shortage of primary care physicians. One approach to counteract these developments might be to reduce primary care physicians' workload supported by the use of health information technology (HIT) and non-physician practice staff. In 2009, the U.S. Commonwealth Fund conducted an international survey of primary care physicians which the present secondary descriptive analysis is based on. The aim of this analysis was twofold: First, to explore to what extend German primary care physicians already get support by HIT and non-physician practice staff, and second, to show possible future perspectives. Methods: The CWF questionnaire was sent to a representative random sample of 1,500 primary care physicians all over Germany. The data was descriptively analyzed. Group comparisons regarding differences in gender and age groups were made by means of Chi Square Tests for categorical variables. An alpha-level of p 〈 0.05 was used for statistical significance. Results: Altogether 715 primary care physicians answered the questionnaire (response rate 49%). Seventy percent of the physicians use electronic medical records. Technical features such as electronic ordering and access to laboratory parameters are mainly used. However, the majority does not routinely use technical functions for drug prescribing, reminder-systems for guideline-based interventions or recall of patients. Six percent of surveyed physicians are able to transfer prescriptions electronically to a pharmacy, 1% use email communication with patients regularly. Seventy-two percent of primary care physicians get support by non-physician practice staff in patient care, mostly in administrative tasks or routine preventive services. One fourth of physicians is supported in telephone calls to the patient or in patient education and counseling. Conclusion: Within this sample the majority of primary care physicians get support by HIT and non-physician practice staff in their daily work. However, the potential has not yet been fully used. Supportive technical functions like electronic alarm functions for medication or electronic prescribing should be improved technically and more adapted to physicians' needs. To warrant pro-active health care, recall and reminder systems should get refined to encourage their use. Adequately qualified non-physician practice staff could play a more active role in patient care. Reimbursement should not only be linked to doctors', but also to non-physician practice staff services.

Description: The development of genomic tests is one of the most significant technological advances in medical testing in recent decades. As these tests become increasingly available, so does the need for a pragmatic framework to evaluate the evidence base and evidence gaps in order to facilitate informed decision-making. In this article we describe such a framework that can provide a common language and benchmarks for different stakeholders of genomic testing. Each stakeholder can use this framework to specify their respective thresholds for decision-making, depending on their perspective and particular needs. This framework is applicable across a broad range of test applications and can be helpful in the application and communication of a regulatory science for genomic testing. Our framework builds upon existing work and incorporates principles familiar to researchers involved in medical testing (both diagnostic and prognostic) generally, as well as those involved in genomic testing. This framework is organized around six phases in the development of genomic tests beginning with marker identification and ending with population impact, and highlights the important knowledge gaps that need to be filled in establishing the clinical relevance of a test. Our framework focuses on the clinical appropriateness of the four main dimensions of test research questions (population/setting, intervention/index test, comparators/reference test, and outcomes) rather than prescribing a hierarchy of study designs that should be used to address each phase.

Description: Background: The rate of elective surgeries varies dramatically by geography in the United States. For many of these surgeries, there is not clear evidence of their relative merits over alternate treatment choices and there are significant tradeoffs in short- and long-term risks and benefits of selecting one treatment option over another. Conditions and symptoms for which there is this lack of a single clear evidence-based treatment choice present great opportunities for patient and provider collaboration on decision making; back pain and joint osteoarthritis are two such ailments. A number of decision aids are in active use to encourage this shared decision-making process. Decision aids have been assessed in formal studies that demonstrate increases in patient knowledge, increases in patient-provider engagement, and reduction in surgery rates. These studies have not widely demonstrated the added benefit of health coaching in support of shared decision making nor have they commonly provided strong evidence of cost reductions. In order to add to this evidence base, we undertook a comparative study testing the relative impact on health utilization and costs of active outreach through interactive voice response technology to encourage health coaching in support of shared decision making in comparison to mailed outreach or no outreach. This study focused on individuals with back pain or joint pain. Methods: We conducted four waves of stratified randomized comparisons for individuals with risk for back, hip, or knee surgery who did not have claims-based evidence of one or more of five chronic conditions and were eligible for population care management services within three large regional health plans in the United States. An interactive voice response (IVR) form of outreach that included the capability for individuals to directly connect with health coaches telephonically, known as AutoDialog(R), was compared to a control (mailed outreach or natural levels of inbound calling depending on the study wave). In total, the study include 24,167 adults with commercial and Medicare Advantage private coverage at three health plans and at risk for lumbar back surgery, hip repair/replacement, or knee repair/replacement. Results: Interactive voice response outreach led to 10.7 (P-value 〈 .0001) times as many inbound calls within 30 days as the control. Over 180 days, the IVR group ("intervention") had 67 percent (P-value 〈 .0001) more health coach communications and agreed to be sent 3.2 (P-value 〈 .0001) as many DVD- and/or booklet-based decision aids. Targeted surgeries were reduced by 6.7 percent (P-value = .6039). Overall costs were lower by 4.9 percent (P-value = .055). Costs that were not related to maternity, cancer, trauma and substance abuse ("actionable costs") were reduced by 6.5 percent (P-value = .0286). Conclusions: IVR with a transfer-to-health coach-option significantly increased levels of health coaching compared to mailed or no outreach and lead to significantly reduced actionable medical costs. Providing high levels of health coaching to individuals with these types of risks appears to have produced important levels of actionable medical cost reductions. We believe this impact resulted from more informed and engaged health care decision making.

Description: Background: One area where the use of information and communication technology (ICT), or eHealth, could be developed is the home health care of premature infants. The aim of this randomized controlled study was to investigate whether the use of video conferencing or a web application improves parents' satisfaction in taking care of a premature infant at home and decreases the need of home visits. In addition, nurses' attitudes regarding the use of these tools were examined.MethodThirty-four families were randomized to one of three groups before their premature infant was discharged from the hospital to home health care: a control group receiving standard home health care (13 families); a web group receiving home health care supplemented with the use of a web application (12 families); a video group with home health care supplemented with video conferencing using Skype (9 families). Families and nursing staff answered questionnaires about the usefulness of ICT. In addition, semi-structured interviews were conducted with 16 families. Results: All the parents in the web group found the web application easy to use. 83% of the families thought it was good to have access to their child's data through the application. All the families in the video group found Skype easy to use and were satisfied with the video calls. 88% of the families thought that video calls were better than ordinary phone calls. 33% of the families in the web group and 75% of those in the video group thought the need for home visits was decreased by the web application or Skype. 50% of the families in the web group and 100% of those in the video group thought the web application or the video calls had helped them feel more confident in caring for their child. Most of the nurses were motivated to use ICT but some were reluctant and avoided using the web application and video conferencing. Conclusion: The families were satisfied with both the web application and video conferencing. The families readily embraced the use of ICT, whereas motivating some of the nurses to accept and use ICT was a major challenge.

Description: Background: A small pre-test study was conducted to ascertain potential harm and anxiety associated with distributing information about possible cancer treatment options at the time of biopsy, prior to knowledge about a definitive cancer diagnosis. Priming men about the availability of multiple options before they have a confirmed diagnosis may be an opportunity to engage patients in more informed decision-making. Methods: Men with an elevated PSA test or suspicious Digital Rectal Examination (DRE) who were referred to a urology clinic for a biopsy were randomized to receive either the clinic's usual care (UC) biopsy instruction sheet (n = 11) or a pre-biopsy educational (ED) packet containing the biopsy instruction sheet along with a booklet about the biopsy procedure and a prostate cancer treatment decision aid originally written for newly diagnosed men that described in detail possible treatment options (n = 18). Results: A total of 62% of men who were approached agreed to be randomized, and 83% of the ED group confirmed they used the materials. Anxiety scores were similar for both groups while awaiting the biopsy procedure, with anxiety scores trending lower in the ED group: 41.2 on a prostate-specific anxiety instrument compared to 51.7 in the UC group (p = 0.13). ED participants reported better overall quality of life while awaiting biopsy compared to the UC group (76.4 vs. 48.5, p = 0.01). The small number of men in the ED group who went on to be diagnosed with cancer reported being better informed about the risks and side effects of each option compared to men diagnosed with cancer in the UC group (p = 0.07). In qualitative discussions, men generally reported they found the pre-biopsy materials to be helpful and indicated having information about possible treatment options reduced their anxiety. However, 2 of 18 men reported they did not want to think about treatment options until after they knew their biopsy results. Conclusions: In this small sample offering pre-biopsy education about potential treatment options was generally well received by patients, appeared to be beneficial to men who went on to be diagnosed, and did not appear to increase anxiety unnecessarily among those who had a negative biopsy.

Description: Background: In recent years, there have been numerous initiatives undertaken to describe critical information needs related to the collection, management, analysis, and dissemination of data in support of biomedical research (J Investig Med 54:327-333, 2006); (J Am Med Inform Assoc 16:316--327, 2009); (Physiol Genomics 39:131-140, 2009); (J Am Med Inform Assoc 18:354--357, 2011). A common theme spanning such reports has been the importance of understanding and optimizing people, organizational, and leadership factors in order to achieve the promise of efficient and timely research (J Am Med Inform Assoc 15:283--289, 2008). With the emergence of clinical and translational science (CTS) as a national priority in the United States, and the corresponding growth in the scale and scope of CTS research programs, the acuity of such information needs continues to increase (JAMA 289:1278--1287, 2003); (N Engl J Med 353:1621--1623, 2005); (Sci Transl Med 3:90, 2011). At the same time, systematic evaluations of optimal people, organizational, and leadership factors that influence the provision of data, information, and knowledge management technologies and methods are notably lacking. Methods: In response to the preceding gap in knowledge, we have conducted both: 1) a structured survey of domain experts at Academic Health Centers (AHCs); and 2) a subsequent thematic analysis of public-domain documentation provided by those same organizations. The results of these approaches were then used to identify critical factors that may influence access to informatics expertise and resources relevant to the CTS domain. Results: A total of 31 domain experts, spanning the Biomedical Informatics (BMI), Computer Science (CS), Information Science (IS), and Information Technology (IT) disciplines participated in a structured surveyprocess. At a high level, respondents identified notable differences in theaccess to BMI, CS, and IT expertise and services depending on the establishment of a formal BMI academic unit and the perceived relationship between BMI, CS, IS, and IT leaders. Subsequent thematic analysis of the aforementioned public domain documents demonstrated a discordance between perceived and reported integration across and between BMI, CS, IS, and IT programs and leaders with relevance to the CTS domain. Conclusion: Differences in people, organization, and leadership factors do influence the effectiveness of CTS programs, particularly with regard to the ability to access and leverage BMI, CS, IS, and IT expertise and resources. Based on this finding, we believe that the development of a better understanding of how optimal BMI, CS, IS, and IT organizational structures and leadership models are designed and implemented is critical to both the advancement of CTS and ultimately, to improvements in the quality, safety, and effectiveness of healthcare.

Description: Background: Smartphones and tablet computers have become an integral part of our lives. One of their key features is the possibility of installing third-party apps. These apps can be very helpful for improving health and healthcare. However, medical professionals and citizens are currently being overloaded with health apps. Consequently, they will have difficulty with finding the right app, and information and features are fragmented over too many apps, thereby limiting their usefulness.DiscussionIn order to combat health app overload, suppliers of apps need to do three things. One, join the open source movement, so that a few apps can work as gateway to medical information by incorporating information from different sources. Two, standardize content, so that the information provided via apps is readable. And third, in order to prevent information overload from occurring within an app, content should be personalized towards an individual's characteristics and context.SummarySuppliers of medical information and features need to join the open source movement and must make use of standardized medical information formats, in order to allow third parties to create valuable, mobile gateway apps. This can prevent the occurrence of health app overload. By going along in these trends, we can make health apps achieve the impact on healthcare quality and citizens' health many of us envision.

Description: Background: Type 2 diabetes is an increasingly common chronic condition whose prognosis can be improved by patient involvement and self-management. Patient involvement can be fostered by web-based Interactive Health Communication Applications (IHCAs) combining health information with decision support, social support and/or behaviour change support. They reach great numbers of patients at low cost and provide high-quality information and support at the time, place and learning speed patients prefer. Still, online tools often suffer from high attrition. Tailoring content and tone of IHCAs to the individual patient s needs might improve their effectiveness. This study aims to test the effectiveness and usage of a tailored IHCA combining health information with decision support and behaviour change support for patients with type 2 diabetes. Methods: The effectiveness and usage of the tailored IHCA will be tested against a standard website with identical content in a single-blinded randomized trial with a parallel design. The content covers information on type 2 diabetes, its complications and sequelae, and its treatment options including health behaviour. In the intervention group the content is delivered in dialogue form, tailored to relevant patient characteristics (health literacy, attitudes towards self-care, and barriers to insulin treatment). In the control group the different sections are presented in a content tree, without any tailoring. Participants are blinded to group assignment. Eligibility criteria are age 〉= 18 years, self-reported type 2 diabetes, and Internet access. The study aims to include 414 participants in order to detect the expected small effect (Cohen's d=0.2), with measurements at baseline, directly after the first visit, and at 3-month follow-up. The primary hypothesis is that the tailored IHCA has larger effects on diabetes knowledge and patient empowerment (primary outcomes) than the standard website. Secondary outcomes are website usage as well as decisional conflict and preparation for decision making. All measurements are online self-report questionnaires.DiscussionIHCAs are a promising way to foster diabetes knowledge and self-management competencies. The present trial tries to increase the knowledge on how to develop more effective IHCAs for patients with type 2 diabetes.Trial registration: International Clinical Trials Registry DRKS00003322

Description: Background: Few educational resources have been developed to inform patients' renal replacement therapy (RRT) selection decisions. Patients progressing toward end stage renal disease (ESRD) must decide among multiple treatment options with varying characteristics. Complex information about treatments must be adequately conveyed to patients with different educational backgrounds and informational needs. Decisions about treatment options also require family input, as families often participate in patients' treatment and support patients' decisions. We describe the development, design, and preliminary evaluation of an informational, evidence-based, and patient-and family-centered decision aid for patients with ESRD and varying levels of health literacy, health numeracy, and cognitive function. Methods: We designed a decision aid comprising a complementary video and informational handbook. We based our development process on data previously obtained from qualitative focus groups and systematic literature reviews. We simultaneously developed the video and handbook in "stages." For the video, stages included (1) directed interviews with culturally appropriate patients and families and preliminary script development, (2) video production, and (3) screening the video with patients and their families. For the handbook, stages comprised (1) preliminary content design, (2) a mixed-methods pilot study among diverse patients to assess comprehension of handbook material, and (3) screening the handbook with patients and their families. Results: The video and handbook both addressed potential benefits and trade-offs of treatment selections. The 50-minute video consisted of demographically diverse patients and their families describing their positive and negative experiences with selecting a treatment option. The video also incorporated health professionals' testimonials regarding various considerations that might influence patients' and families' treatment selections. The handbook was comprised of written words, pictures of patients and health care providers, and diagrams describing the findings and quality of scientific studies comparing treatments. The handbook text was written at a 4th to 6th grade reading level. Pilot study results demonstrated that a majority of patients could understand information presented in the handbook. Patient and families screening the nearly completed video and handbook reviewed the materials favorably. Conclusions: This rigorously designed decision aid may help patients and families make informed decisions about their treatment options for RRT that are well aligned with their values.

Description: Background: The U.S. Centers for Medicare and Medicaid Services established the Electronic Health Record (EHR) Incentive Program in 2009 to stimulate the adoption of EHRs. One component of the program requires eligible providers to implement clinical decision support (CDS) interventions that can improve performance on one or more quality measures pre-selected for each specialty. Because the unique decision-making challenges and existing HIT capabilities vary widely across specialties, the development of meaningful objectives for CDS within such programs must be supported by deliberative analysis.DesignWe developed a conceptual framework and protocol that combines evidence review with expert opinion to elicit clinically meaningful objectives for CDS directly from specialists. The framework links objectives for CDS to specialty-specific performance gaps while ensuring that a workable set of CDS opportunities are available to providers to address each performance gap. Performance gaps may include those with well-established quality measures but also priorities identified by specialists based on their clinical experience. Moreover, objectives are not constrained to performance gaps with existing CDS technologies, but rather may include those for which CDS tools might reasonably be expected to be developed in the near term, for example, by the beginning of Stage 3 of the EHR Incentive program. The protocol uses a modified Delphi expert panel process to elicit and prioritize CDS meaningful use objectives. Experts first rate the importance of performance gaps, beginning with a candidate list generated through an environmental scan and supplemented through nominations by panelists. For the highest priority performance gaps, panelists then rate the extent to which existing or future CDS interventions, characterized jointly as "CDS opportunities," might impact each performance gap and the extent to which each CDS opportunity is compatible with specialists' clinical workflows. The protocol was tested by expert panels representing four clinical specialties: oncology, orthopedic surgery, interventional cardiology, and pediatrics.

Description: Background: Venous thromboembolism (VTE) causes morbidity and mortality in hospitalized patients, and regulators and payors are encouraging the use of systems to prevent them. Here, we examine the effect of a computerized clinical decision support (CDS) intervention implemented across a multi-hospital academic health system on VTE prophylaxis and events. Methods: The study included 223,062 inpatients admitted between April 2007 and May 2010, and used administrative and clinical data. The intervention was integrated into a commercial electronic health record (EHR) in an admission orderset used for all admissions. Three time periods were examined: baseline (period 1), and the time after implementation of the first CDS intervention (period 2) and a second iteration (period 3). Providers were prompted to accept or decline prophylaxis based on patient risk. Time series analyses examined the impact of the intervention on VTE prophylaxis during time periods two and three compared to baseline, and a simple pre-post design examined impact on VTE events and bleeds secondary to anticoagulation. VTE prophylaxis and events were also examined in a prespecified surgical subset of our population meeting the public reporting criteria defined by the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator (PSI). Results: Unadjusted analyses suggested that "recommended", "any", and "pharmacologic" prophylaxis increased from baseline to the last study period (27.1% to 51.9%, 56.7% to 78.1%, and 42.0% to 54.4% respectively; p 〈 0.01 for all comparisons). Results were significant across all hospitals and the health system overall. Interrupted time series analyses suggested that our intervention increased the use of "recommended" and "any" prophylaxis by 7.9% and 9.6% respectively from baseline to time period 2 (p 〈 0.01 for both comparisons); and 6.6% and 9.6% respectively from baseline to the combined time periods 2 and 3 (p 〈 0.01 for both comparisons). There were no significant changes in "pharmacologic" prophylaxis in the adjusted model. The overall percent of patients with VTE increased from baseline to the last study period (2.0% to 2.2%; p = 0.03), but an analysis excluding patients with VTE "present on admission" (POA) demonstrated no difference in events (1.3% to 1.3%; p = 0.80). Overall bleeds did not significantly change. An analysis examining VTE prophylaxis and events in a surgical subset of patients defined by the AHRQ PSI demonstrated increased "recommended", "any", and "pharmacologic" prophylaxis from baseline to the last study period (32.3% to 60.0%, 62.8% to 85.7%, and 47.9% to 63.3% respectively; p 〈 0.01 for all comparisons) as well as reduced VTE events (2.2% to 1.7%; p 〈 0.01). Conclusions: The CDS intervention was associated with an increase in "recommended" and "any" VTE prophylaxis across the multi-hospital academic health system. The intervention was also associated with increased VTE rates in the overall study population, but a subanalysis using only admissions with appropriate POA documentation suggested no change in VTE rates, and a prespecified analysis of a surgical subset of our sample as defined by the AHRQ PSI for public reporting purposes suggested reduced VTE. This intervention was created in a commonly used commercial EHR and is scalable across institutions with similar systems.

Description: Background: Meningitis means an inflammation of the meninges, or the membrane around the brain and spinal cord. It might be caused by a number of factors, but infectious meningitis is due to multiplication of fungal, viral or bacterial organisms. A number of studies showed that the diagnosis and treatment management of meningitis is a complex and common problem and a special attention is demanded. In this work, our attention primarily has focused on the process of making decisions in medical domain by using Fuzzy Cognitive Map, to model physicians-experts' behavior in the decision task related to this life threatening disease. Methods: Fuzzy cognitive mapping (FCM) is a method for analysing and depicting human perception of a given system. The method produces a conceptual model which is not limited by exact values and measurements, and thus is well suited to represent relatively unstructured knowledge and causalities expressed in imprecise forms. A team of doctors (physicians), comprising of four paediatricians, has been formed to define the number and types of sign/symptoms and other life-style related factors used in deciding the presence and absence of meningitis disease. The FCM model, consisting of 20 concepts nodes, has been designed by the team paediatricians after through deliberations. The 19 concepts are the symptoms and risks taken under consideration for the decision on disease. Results: The paediatricians were supplied with a form containing various input parameters to be filled at the time of diagnosing meningitis among infants and children. The paediatricians supplied back the cases of forty different children with age ranging from 2 months through 7 years. The physicians' decision was available for each of the cases as whether treated for meningitis disease or not. The physicians' opinions were used as "gold standard" for the model evaluation. The system predicted the outcome in all forty cases with an accuracy of 95%, thus showing its functionality and demonstrating that the use of the FCMs as dynamic models is reliable and good. Conclusions: This work elaborates the development of the knowledge based system, using the formalization of FCMs for meningitis diagnosis in children and infants. The results have shown that the suggested FCM-based tool gives a front-end decision on diagnosing meningitis and could be considered as helpful reference for physicians and patients.

Description: Background: Dual processing theory of human cognition postulates that reasoning and decision-making can be described as a function of both an intuitive, experiential, affective system (system I) and/or an analytical, deliberative (system II) processing system. To date no formal descriptive model of medical decision-making based on dual processing theory has been developed. Here we postulate such a model and apply it to a common clinical situation: whether treatment should be administered to the patient who may or may not have a disease. Methods: We developed a mathematical model in which we linked a recently proposed descriptive psychological model of cognition with the threshold model of medical decision-making and show how this approach can be used to better understand decision-making at the bedside and explain the widespread variation in treatments observed in clinical practice. Results: We show that physician's beliefs about whether to treat at higher (lower) probability levels compared to the prescriptive therapeutic thresholds obtained via system II processing is moderated by system I and the ratio of benefit and harms as evaluated by both system I and II. Under some conditions, the system I decision maker's threshold may dramatically drop below the expected utility threshold derived by system II. This can explain the overtreatment often seen in the contemporary practice. The opposite can also occur as in the situations where empirical evidence is considered unreliable, or when cognitive processes of decision-makers are biased through recent experience: the threshold will increase relative to the normative threshold value derived via system II using expected utility threshold. This inclination for the higher diagnostic certainty may, in turn, explain undertreatment that is also documented in the current medical practice. Conclusions: We have developed the first dual processing model of medical decision-making that has potential to enrich the current medical decision-making field, which is still to the large extent dominated by expected utility theory. The model also provides a platform for reconciling two groups of competing dual processing theories (parallel competitive with default-interventionalist theories).

Description: Background: In todays short stay hospital settings the contact time for patients is reduced. However, itseems to be more important for the patients that the healthcare professionals are easy to get incontact with during the whole course of treatment, and to have the opportunity to exchangeinformation, as a basis for obtaining individualized information and support. Therefore, theaim was to explore the ability of a dialogue-based application to contribute to accessibility ofthe healthcare professionals and exchangeability of information.MethodAn application for online written and asynchronous contacts was developed, implemented inclinical practice, and evaluated. The qualitative effect of the online contact was exploredusing a Web-based survey comprised of open-ended questions. Results: Patients valued the online contacts and experienced feelings of partnership in dialogue, in aflexible and calm environment, which supported their ability to be active partners andfeelings of freedom and security. Conclusion: The online asynchronous written environment can contribute to accessibility andexchangeability, and add new possibilities for dialogues from which the patients can benefit.The individualized information obtained via online contact empowers the patients. TheInternet-based contacts are a way to differentiate and expand the possibilities for contactsoutside the few scheduled face-to-face hospital contacts.

Description: Background: Decisions concerning drug safety and efficacy are generally based on pivotal evidence provided by clinical trials. Unfortunately, finding the relevant clinical trials is difficult and their results are only available in text-based reports. Systematic reviews aim to provide a comprehensive overview of the evidence in a specific area, but may not provide the data required for decision making. Methods: We review and analyze the existing information systems and standards for aggregate level clinical trials information from the perspective of systematic review and evidence-based decision making. Results: The technology currently used has major shortcomings, which cause deficiencies in the transfer, traceability and availability of clinical trials information. Specifically, data available to decision makers is insufficiently structured, and consequently the decisions cannot be properly traced back to the underlying evidence. Regulatory submission, trial publication, trial registration, and systematic review produce unstructured datasets that are insufficient for supporting evidence-based decision making. Conclusions: The current situation is a hindrance to policy decision makers as it prevents fully transparent decision making and the development of more advanced decision support systems. Addressing the identified deficiencies would enable more efficient, informed, and transparent evidence-based medical decision making.

Description: Background: In myocardial perfusion scintigraphy (MPS), typically a stress and a rest study is performed. If the stress study is considered normal, there is no need for a subsequent rest study. The aim of the study was to determine whether nuclear medicine technologists are able to assess the necessity of a rest study. Methods: Gated MPS using a 2-day 99mTc protocol for 121 consecutive patients were studied. Visual interpretation by 3 physicians was used as gold standard for determining the need for a rest study based on the stress images. All nuclear medicine technologists performing MPS had to review 82 training cases of stress MPS images with comments regarding the need for rest studies, and thereafter a test consisting of 20 stress MPS images. After passing this test, the nuclear medicine technologists in charge of a stress MPS study assessed whether a rest study was needed or not or if he/she was uncertain and wanted to consult a physician. After that, the physician in charge interpreted the images and decided whether a rest study was required or not. Results: The nuclear medicine technologists and the physicians in clinical routine agreed in 103 of the 107 cases (96%) for which the technologists felt certain regarding the need for a rest study. In the remaining 14 cases the technologists were uncertain, i.e. wanted to consult a physician. The agreement between the technologists and the physicians in clinical routine was very good, resulting in a kappa value of 0.92. There was no statistically significant difference in the evaluations made by technicians and physicians (P=0.617). Conclusions: The nuclear medicine technologists were able to accurately determine whether a rest study was necessary. There was very good agreement between nuclear medicine technologists and physicians in the assessment of the need for a rest study. If the technologists can make this decision, the effectiveness of the nuclear medicine department will improve.

Description: Background: Refugees experience multiple health and social needs. This requires an integrated approach to care in the countries of resettlement, including Canada. Perhaps, interactive eHealth tools could build bridges between medical and social care in a timely manner. The authors developed and piloted a multi-risk Computer-assisted Psychosocial Risk Assessment (CaPRA) tool for Afghan refugees visiting a community health center. The iPad based CaPRA survey was completed by the patients in their own language before seeing the medical practitioner. The computer then generated individualized feedback for the patient and provider with suggestions about available services. Methods: A pilot randomized trial was conducted with adult Afghan refugees who could read Dari/Farsi or English language. Consenting patients were randomly assigned to the CaPRA (intervention) or usual care (control) group. All patients completed a paper-pencil exit survey. The primary outcome was patient intention to see a psychosocial counselor. The secondary outcomes were patient acceptance of the tool and visit satisfaction. Results: Out of 199 approached patients, 64 were eligible and 50 consented and one withdrew (CaPRA = 25; usual care = 24). On average, participants were 37.6 years of age and had lived 3.4 years in Canada. Seventy-two percent of participants in CaPRA group had intention to visit a psychosocial counselor, compared to 46 % in usual care group [X2 (1)] =3.47, p = 0.06]. On a 5-point scale, CaPRA group participants agreed with the benefits of the tool (mean = 4) and were 'unsure' about possible barriers to interact with the clinicians (mean = 2.8) or to privacy of information (mean = 2.8) in CaPRA mediated visits. On a 5-point scale, the two groups were alike in patient satisfaction (mean = 4.3). Conclusion: The studied eHealth tool offers a promising model to integrate medical and social care to address the health and settlement needs of refugees. The tool's potential is discussed in relation to implications for healthcare practice. The study should be replicated with a larger sample to generalize the results while controlling for potential confounders.

Description: Background: A UK Register of people with Multiple Sclerosis has been developed to address the need foran increased knowledge-base about MS. The Register is being populated via: a web-basedportal; NHS neurology clinical systems; and administrative data sources. The data are deidentifiedand linked at the individual level. At the outset, it was not known whether peoplewith MS would wish to participate in the UK MS Register by personally contributing theirdata to the Register via a web-based system. Therefore, the research aim of this work was tobuild an internet-mounted recruitment and consenting technology for people with MultipleSclerosis, and to assess its feasibility as a questionnaire delivery platform to contribute datato the UK MS Register, by determining whether the information provided could be used todescribe a cohort of people with MS. Methods: The web portal was developed using VB.net and JQuery with a Microsoft SQL 2008database. UK adults with MS can self-register and enter data about themselves by completingvalidated questionnaires. Descriptive statistics were used to characterise the respondents. Results: The web portal was launched in May 2011, and in first three months 7,279 individualsregistered on the portal. The ratio of men to women was 1:2.4 (n = 5,899), the mean selfreportedage at first symptoms was 33.8 (SD 10.5) years, and at diagnosis 39.6 (SD 10.3)years (n = 4,401). The reported types of MS were: 15% primary progressive, 63% relapsingremitting,8% secondary progressive, and 14% unknown (n = 5,400). These characteristics aresimilar to those of the prevalent MS population. Employment rates, sickness/disability rates,ethnicity and educational qualifications were compared with the general UK population.Information about the respondents' experience of early symptoms and the process ofdiagnosis, plus living arrangements are also reported. Conclusions: These initial findings from the MS Register portal demonstrate the feasibility of collectingdata about people with MS via a web platform, and show that sufficient information can begathered to characterise a cohort of people with MS. The innovative design of the UK MSregister, bringing together three disparate sources of data, is creating a rich resource forresearch into this condition.

Description: Background: Online psychiatric texts are natural language texts expressing depressive problems, publishedby Internet users via community-based web services such as web forums, message boards andblogs. Understanding the cause-effect relations embedded in these psychiatric texts canprovide insight into the authors' problems, thus increasing the effectiveness of onlinepsychiatric services. Methods: Previous studies have proposed the use of word pairs extracted from a set of sentence pairs toidentify cause-effect relations between sentences. A word pair is made up of two words, withone coming from the cause text span and the other from the effect text span. Analysis of therelationship between these words can be used to capture individual word associationsbetween cause and effect sentences. For instance, (broke up, life) and (boyfriend,meaningless) are two word pairs extracted from the sentence pair: "I broke up with myboyfriend. Life is now meaningless to me". The major limitation of word pairs is thatindividual words in sentences usually cannot reflect the exact meaning of the cause and effectevents, and thus may produce semantically incomplete word pairs, as the previous examplesshow. Therefore, this study proposes the use of inter-sentential language patterns such as 〈 , 〉 to detect causality between sentences. Theinter-sentential language patterns can capture associations among multiple words within andbetween sentences, thus can provide more precise information than word pairs. To acquireinter-sentential language patterns, we develop a text mining framework by extending theclassical association rule mining algorithm such that it can discover frequently co-occurringpatterns across the sentence boundary. Results: Performance was evaluated on a corpus of texts collected from PsychPark(http://www.psychpark.org), a virtual psychiatric clinic maintained by a group of volunteerprofessionals from the Taiwan Association of Mental Health Informatics. Experimentalresults show that the use of inter-sentential language patterns outperformed the use of wordpairs proposed in previous studies. Conclusions: This study demonstrates the acquisition of inter-sentential language patterns for causalitydetection from online psychiatric texts. Such semantically more complete and precise featurescan improve causality detection performance.

Description: Background: Artificial neural networks (ANNs) are widely studied for evaluating diseases. This paper discusses the intelligence mode of an ANN in grading the diagnosis of liver fibrosis by duplex ultrasonogaphy. Methods: 239 patients who were confirmed as having liver fibrosis or cirrhosis by ultrasound guided liver biopsy were investigated in this study. We quantified ultrasonographic parameters as significant parameters using a data optimization procedure applied to an ANN. 179 patients were typed at random as the training group; 60 additional patients were consequently enrolled as the validating group. Performance of the ANN was evaluated according to accuracy, sensitivity, specificity, Youden's index and receiver operating characteristic (ROC) analysis. Results: 5 ultrasonographic parameters; i.e., the liver parenchyma, thickness of spleen, hepatic vein (HV) waveform, hepatic artery pulsatile index (HAPI) and HV damping index (HVDI), were enrolled as the input neurons in the ANN model. The sensitivity, specificity and accuracy of the ANN model for quantitative diagnosis of liver fibrosis were 95.0%, 85.0% and 88.3%, respectively. The Youden's index (YI) was 0.80. Conclusions: The established ANN model had good sensitivity and specificity in quantitative diagnosis of hepatic fibrosis or liver cirrhosis. Our study suggests that the ANN model based on duplex ultrasound may help non-invasive grading diagnosis of liver fibrosis in clinical practice.

Description: Background: The treatment of cancer associated thrombosis (CAT) is well established, with level 1A evidence to support the recommendation of a low molecular weight heparin (LMWH) by daily injection for 3-6 months. However, registry data suggest compliance to clinical guidelines is poor. Clinicians face particular challenges in treating CAT in advanced cancer patients due to shorter life expectancy, increased bleeding risk and concerns that self injection may be too burdensome. For these reasons decision making around the diagnosis and management of CAT in people with advanced cancer, can be complex, and should focus on its likely net benefit for the patient. We explored factors that influence doctors' decision making in this situation and sought to gain an understanding of the barriers and facilitators to the application of best practice. Methods: Think aloud exercises using standardised case scenarios, and individual in depth interviews were conducted. All were transcribed. The think aloud exercises were analysed using Protocol Analysis and the interviews using Framework Analysis.Participants: 46 participants took part in the think aloud exercises and 45 participants were interviewed in depth. Each group included oncologists, palliative physicians and general practitioners and included both senior doctors and those in training.Setting: Two Strategic Health Authority regions, one in the north of England and one in Wales. Results: The following key issues arose from the data synthesis: the importance of patient prognosis; the concept of "appropriateness"; "benefits and burdens" of diagnosis and treatment; LMWH or warfarin for treatment and sources of information which changed practice. Although interlinked, they do describe distinct aspects of the factors that influence doctors in their decisions in this area. Conclusions: The above factors are issues doctors take into account when deciding whether to send a patient to hospital for investigation or to anticoagulate a patient with confirmed or suspected VTE. Many factors interweave and are themselves influenced by and dependent on each other. It is only after all are taken into account that the doctor arrives at the point of referring the patient for investigation. Some factors including logistic and organisational issues appeared to influence whether a patient would be investigated or treated with LMWH for a confirmed VTE. It is important that services are optimised to ensure that these do not hinder the appropriate investigation and management of individual patients.

Description: Background: It is well established that considering users is an important aspect of medical devicedevelopment. However it is also well established that there are numerous barriers tosuccessfully conducting user research and integrating the results into product development. Itis not sufficient to simply conduct user research, it must also be effectively integrated intoproduct development Methods: A case study of the development of a new medical imaging device was conducted to examinein detail how users were involved in a medical device development project. Two userresearch studies were conducted: a requirements elicitation interview study and an earlyprototype evaluation using contextual inquiry. A descriptive in situ approach was taken toinvestigate how these studies contributed to the product development process and how theresults of this work influenced the development of the technology. Data was collectedqualitatively through interviews with the development team, participant observation atdevelopment meetings and document analysis. The focus was on investigating the barriersthat exist to prevent user data from being integrated into product development. Results: A number of individual, organisational and system barriers were identified that functioned toprevent the results of the user research being fully integrated into development. The user andtechnological aspects of development were seen as separate work streams duringdevelopment. The expectations of the developers were that user research would collectrequirements for the appearance of the device, rather than challenge its fundamental concept.The manner that the user data was communicated to the development team was not effectivein conveying the significance or breadth of the findings. Conclusion: There are a range of informal and formal organisational processes that can affect the uptakeof user data during medical device development. Adopting formal decision making processesmay assist manufacturers to take a more integrated and reflective approach to development,which should result in improved business decisions and a higher quality end product.

Description: Background: The major problem facing health and social care systems globally today is the growingchallenge of an elderly population with complex health and social care needs. A longstandingchallenge to the provision of high quality, effectively coordinated care for those withcomplex needs has been the historical separation of health and social care. Access to timelyand accurate data about patients and their treatments has the potential to deliver better care atless cost. Methods: To explore the way in which structural, professional and geographical boundaries haveaffected e-health implementation in health and social care, through an empirical study of theimplementation of an electronic version of Single Shared Assessment (SSA) in Scotland,using three retrospective, qualitative case studies in three different health board locations. Results: Progress in effectively sharing electronic data had been slow and uneven. One cause was thepresence of established structural boundaries, which lead to competing priorities,incompatible IT systems and infrastructure, and poor cooperation. A second cause was thepresence of established professional boundaries, which affect staffs understanding andacceptance of data sharing and their information requirements. Geographical boundariesfeatured but less prominently and contrasting perspectives were found with regard to issuessuch as co-location of health and social care professionals. Conclusions: To provide holistic care to those with complex health and social care needs, it is essential thatwe develop integrated approaches to care delivery. Successful integration needs practicessuch as good project management and governance, ensuring system interoperability,leadership, good training and support, together with clear efforts to improve workingrelations across professional boundaries and communication of a clear project vision. Thisstudy shows that while technological developments make integration possible, long-standingboundaries constitute substantial risks to IT implementations across the health and social careinterface which those initiating major changes would do well to consider before committingto the investment.

Description: Background: NICE recommends computerised cognitive behavioural therapy (cCBT) for the treatment of several mental health problems such as anxiety and depression. cCBT may be one way that services can reduce waiting lists and improve capacity and efficiency. However, there is some doubt about the extent to which the National Health Service (NHS) in the UK is embracing this new health technology in practice. This study aimed to investigate Scottish health service infrastructure and policies that promote or impede the implementation of cCBT in the NHS. Methods: A telephone survey of lead IT staff at all health board areas across Scotland to systematically enquire about the ability of local IT infrastructure and IT policies to support delivery of cCBT. Results: Overall, most of the health boards possess the required software to use cCBT programmes. However, the majority of NHS health boards reported that they lack dedicated computers for patient use, hence access to cCBT at NHS sites is limited. Additionally, local policy in the majority of boards prevent staff from routinely contacting patients via email, skype or instant messenger, making the delivery of short, efficient support sessions difficult. Conclusions: Conclusions: Overall most of the infrastructure is in place but is not utilised in ways that allow effective delivery. For cCBT to be successfully delivered within a guided support model, as recommended by national guidelines, dedicated patient computers should be provided to allow access to online interventions. Additionally, policy should allow staff to support patients in convenient ways such as via email or live chat. These measures would increase the likelihood of achieving Scottish health service targets to reduce waiting time for psychological therapies to 18 weeks.

Description: Background: More than half a million new items of biomedical research are generated every year and added to Medline. How successful are we at applying this steady accumulation of scientific knowledge and so improving the practice of medicine in the USA?DiscussionThe conventional wisdom is that the US healthcare system is plagued by serious cost, access, safety and quality weaknesses. A comprehensive solution must involve the better translation of an abundance of clinical research into improved clinical practice.Yet the application of knowledge (i.e. technology) remains far less well funded and less visible than the generation, synthesis and accumulation of knowledge (i.e. science), and the two are only weakly integrated. Worse, technology is often seen merely as an adjunct to practice, e.g. electronic health records.Several key changes are in order. A helpful first step lies in better understanding the distinction between science and technology, and their complementary strengths and limitations. The absolute level of funding for technology development must be increased as well as being more integrated with traditional science-based clinical research. In such a mission-oriented federal funding strategy, the ties between basic science research and applied research would be better emphasized and strengthened.

Description: Background: Health numeracy is an important factor in how well people make decisions based on medical risk information. However, in many countries, including Japan, numeracy studies have been limited. Methods: To fill this gap, we evaluated health numeracy levels in a sample of Japanese adults by translating two well-known scales that objectively measure basic understanding of math and probability: the 3-item numeracy scale developed by Schwartz and colleagues (the Schwartz scale) and its expanded version, the 11-item numeracy scale developed by Lipkus and colleagues (the Lipkus scale). Results: Participants' performances (n = 300) on the scales were much higher than in original studies conducted in the United States (80% average item-wise correct response rate for Schwartz-J, and 87% for Lipkus-J). This high performance resulted in a ceiling effect on the distributions of both scores, which made it difficult to apply parametric statistical analysis, and limited the interpretation of statistical results. Nevertheless, the data provided some evidence for the reliability and validity of these scales: The reliability of the Japanese versions (Schwartz-J and Lipkus-J) was comparable to the original in terms of their internal consistency (Cronbach's alpha = 0.53 for Schwartz-J and 0.72 for Lipkus-J). Convergent validity was suggested by positive correlations with an existing Japanese health literacy measure (the Test for Ability to Interpret Medical Information developed by Takahashi and colleagues) that contains some items relevant to numeracy. Furthermore, as shown in the previous studies, health numeracy was still associated with framing bias with individuals whose Lipkus-J performance was below the median being significantly influenced by how probability was framed when they rated surgical risks. A significant association was also found using Schwartz-J, which consisted of only three items. Conclusions: Despite relatively high levels of health numeracy according to these scales, numeracy measures are still important determinants underlying susceptibility to framing bias. This suggests that it is important in Japan to identify individuals with low numeracy skills so that risk information can be presented in a way that enables them to correctly understand it. Further investigation is required on effective numeracy measures for such an intervention in Japan.

Description: Electronic health records are increasingly being used to facilitate referral communication in the outpatient setting. However, despite support by technology, referral communication between primary care providers and specialists is often unsatisfactory and is unable to eliminate care delays. This may be in part due to lack of attention to how information and communication technology fits within the social environment of health care. Making electronic referral communication effective requires a multifaceted "socio-technical" approach. Using an 8-dimensional socio-technical model for health information technology as a framework, we describe ten recommendations that represent good clinical practices to design, develop, implement, improve, and monitor electronic referral communication in the outpatient setting. These recommendations were developed on the basis of our previous work, current literature, sound clinical practice, and a systems-based approach to understanding and implementing health information technology solutions. Recommendations are relevant to system designers, practicing clinicians, and other stakeholders considering use of electronic health records to support referral communication.

Description: Background: Interoperable electronic health record (EHR) solutions are currently being implemented in Canada, as in many other countries. Understanding EHR users' perspectives is key to the success of EHR implementation projects. This Delphi study aimed to assess in the Canadian context the applicability, the importance, and the priority of pre-identified factors from a previous mixed-methods systematic review of international literature. Methods: A three-round Delphi study was held with representatives of 4 Canadian EHR user groups defined as partners of the implementation process who use or are expected to use EHR in their everyday activity. These groups are: non-physician healthcare professionals, health information professionals, managers, and physicians. Four bilingual online questionnaire versions were developed from factors identified by the systematic review. Participants were asked to rate the applicability and the importance of each factor. The main outcome measures were consensus and priority. Consensus was defined a priori as strong (〉= 75 %) or moderate (〉= 60-74 %) according to user groups' level of agreement on applicability and importance, partial (〉= 60 %) when participants agreed only on applicability or importance, or as no consensus ( 〈 60 %). Priority for decision-making was defined as factors with strong consensus with scores of 4 or 5 on a five-point Likert scale for applicability and importance. Results: Three Delphi rounds were completed by 64 participants. Levels of consensus of 100 %, 64 %, 64 %, and 44 % were attained on factors submitted to non-physician healthcare professionals, health information professionals, managers, and physicians, respectively. While agreement between and within user groups varied, key factors were prioritized if they were classified as strong (〉= 75 % from questionnaire answers of user groups), for decision-making concerning EHR implementation. The10 factors that were prioritized are perceived usefulness, productivity, motivation, participation of end-users in the implementation strategy, patient and health professional interaction, lack of time and workload, resources availability, management, outcome expectancy, and interoperability. Conclusions: Amongst all factors influencing EHR implementation identified in a previous systematic review, ten were prioritized through this Delphi study. The varying levels of agreement between and within user groups could mean that users' perspectives of each factor are complex and that each user group has unique professional priorities and roles in the EHR implementation process. As more EHR implementations in Canada are completed it will be possible to corroborate this preliminary result with a larger population of EHR users.

Description: Background: Translational research typically requires data abstracted from medical records as well as data collected specifically for research. Unfortunately, many data within electronic health records are represented as text that is not amenable to aggregation for analyses. We present a scalable open source SQL Server Integration Services package, called Regextractor, for including regular expression parsers into a classic extract, transform, and load workflow. We have used Regextractor to abstract discrete data from textual reports from a number of 'machine generated' sources. To validate this package, we created a pulmonary function test data mart and analyzed the quality of the data mart versus manual chart review. Methods: Eleven variables from pulmonary function tests performed closest to the initial clinical evaluation date were studied for 100 randomly selected subjects with scleroderma. One research assistant manually reviewed, abstracted, and entered relevant data into a database. Correlation with data obtained from the automated pulmonary function test data mart within the Northwestern Medical Enterprise Data Warehouse was determined. Results: There was a near perfect (99.5%) agreement between results generated from the Regextractor package and those obtained via manual chart abstraction. The pulmonary function test data mart has been used subsequently to monitor disease progression of patients in the Northwestern Scleroderma Registry. In addition to the pulmonary function test example presented in this manuscript, the Regextractor package has been used to create cardiac catheterization and echocardiography data marts. The Regextractor package was released as open source software in October 2009 and has been downloaded 552 times as of 6/1/2012. Conclusions: Collaboration between clinical researchers and biomedical informatics experts enabled the development and validation of a tool (Regextractor) to parse, abstract and assemble structured data from text data contained in the electronic health record. Regextractor has been successfully used to create additional data marts in other medical domains and is available to the public.

Description: Background: Consumers are increasingly exposed to comparative healthcare information (informationabout the quality of different healthcare providers). Partly because of its complexity, the useof this information has been limited. The objective of this study was to examine how theamount of presented information influences the comprehension and use of comparativehealthcare information when important consumer characteristics and skills are taken intoaccount. Methods: In this randomized controlled experiment, comparative information on total hip or kneesurgery was used as a test case. An online survey was distributed among 800 members of theNIVEL Insurants Panel and 76 hip- or knee surgery patients. Participants were assigned toone of four subgroups, who were shown 3, 7, 11 or 15 quality aspects of three hospitals. Weconducted Kruskall-Wallis tests, Chi-square tests and hierarchical multiple linear regressionanalyses to examine relationships between the amount of information and consumercharacteristics and skills (literacy, numeracy, active choice behaviour) on one hand, andoutcome measures related to effectively using information (comprehension, perceivedusefulness of information, hospital choice, ease of making a choice) on the other hand. Results: 414 people (47%) participated. Regression analysis showed that the amount of informationslightly influenced the comprehension and the perceived usefulness of comparativehealthcare information. It did not affect consumers hospital choice and ease of making thischoice. Consumer characteristics (especially age) and skills (especially literacy) were themost important factors affecting the comprehension of information and the ease of making ahospital choice. For the perceived usefulness of comparative information, active choicebehaviour was the most influencing factor. Conclusion: The effects of the amount of information were not unambiguous. It remains unclear what theideal amount of quality information to be presented would be. Reducing the amount ofinformation will probably not automatically result in more effective use of comparativehealthcare information by consumers. More important, consumer characteristics and skillsappeared to be more influential factors contributing to information comprehension and use.Consequently, we would suggest that more emphasis on improving consumers skills isneeded to enhance the use of comparative healthcare information.

Description: Background: Adjuvant! Online (www.adjuvantonline.com) is an Internet-based software program that allows clinicians to make predictions about the benefits of adjuvant therapy and 10-year survival probability for early-stage breast cancer patients. This model has been validated in Western countries such as the United States, United Kingdom, Canada, Germany, and Holland. The aim of our study was to investigate the performance and accuracy of Adjuvant! Online in a cohort of Taiwanese breast cancer patients. Methods: Data on the prognostic factors and clinical outcomes of 559 breast cancer patients diagnosed at the National Cheng Kung University Hospital in Tainan between 1992 and 2001 were enrolled in the study. Comprehensive demographic, clinical outcome data, and adjuvant treatment data were entered into the Adjuvant! Online program. The outcome prediction at 10 years was compared with the observed and predicted outcomes using Adjuvant! Online. Results: Comparison between low- and high-risk breast cancer patient subgroups showed significant differences in tumor grading, tumor size, and lymph node status (p 〈 0.0001). The mean 10-year predicted death probability in 559 patients was 19.44%, and the observed death probability was 15.56%. Comparison with the Adjuvant! Online-predicted breast cancer-specific survival (BCSS) showed significant differences in the whole cohort (p 〈 0.001). In the low-risk subgroup, the predicted and observed outcomes did not differ significantly (3.69% and 3.85%, respectively). In high-risk patients, Adjuvant! Online overestimated breast cancer-specific survival (p = 0.016); the predicted and observed outcomes were 21.99% and 17.46%, respectively. Conclusions: Adjuvant! Online accurately predicted 10-year outcomes and assisted in decision making about adjuvant treatment in low-risk breast cancer patients in our study, although the results were less accurate in the high-risk subgroup. Development of a prognostic program based on a national database should be considered, especially for high-risk breast cancer patients in Taiwan.

Description: Background: Greater use of computerized decision support (DS) systems could address continuing safetyand quality problems in healthcare, but the healthcare field has struggled to implement DStechnology. This study surveys DS experience across multiple non-healthcare disciplines fornew insights that are generalizable to healthcare provider decisions. In particular, it soughtdesign principles and lessons learned from the other disciplines that could inform efforts toaccelerate the adoption of clinical decision support (CDS). Methods: Our systematic review drew broadly from non-healthcare databases in the basic sciences,social sciences, humanities, engineering, business, and defense: PsychINFO, BusinessSourcePremier, Social Sciences Abstracts, Web of Science, and Defense Technical InformationCenter. Because our interest was in DS that could apply to clinical decisions, we selectedarticles that (1) provided a review, overview, discussion of lessons learned, or an evaluationof design or implementation aspects of DS within a non-healthcare discipline and (2)involved an element of human judgment at the individual level, as opposed to decisions thatcan be fully automated or that are made at the organizational level. Results: Clinical decisions share some similarities with decisions made by military commanders,business managers, and other leaders: they involve assessing new situations and choosingcourses of action with major consequences, under time pressure, and with incompleteinformation. We identified seven high-level DS system design features from the nonhealthcareliterature that could be applied to CDS: providing broad, system-levelperspectives; customizing interfaces to specific users and roles; making the DS reasoningtransparent; presenting data effectively; generating multiple scenarios covering disparateoutcomes (e.g., effective; effective with side effects; ineffective); allowing for contingentadaptations; and facilitating collaboration. The article provides examples of each feature. TheDS literature also emphasizes the importance of organizational culture and training inimplementation success. The literature contrasts "rational-analytic" vs. "naturalistic-intuitive"decision-making styles, but the best approach is often a balanced approach that combinesboth styles. It is also important for DS systems to enable exploration of multiple assumptions,and incorporation of new information in response to changing circumstances. Conclusions: Complex, high-level decision-making has common features across disciplines as seeminglydisparate as defense, business, and healthcare. National efforts to advance the healthinformation technology agenda through broader CDS adoption could benefit by applying theDS principles identified in this review.

Description: Background: Compared with non-Latinos, Latinos in the US have low rates of colorectal cancer (CRC) screening and low rates of knowledge regarding CRC screening tests and guidelines. Spanish speaking Latinos have particularly low CRC screening rates and screening knowledge. Our purpose was twofold: (1) to evaluate the effect of a computer-based, Spanish-language CRC screening decision aid on screening knowledge, intent to obtain screening, and screening selfefficacy in a community sample of Latinos with limited English proficiency (LEP); and (2) to survey these decision aid viewers at four months to determine their rates of CRC discussions with a health care provider as well as their rates of screening test completion. Methods: We recruited 50-75 year old Latinos with LEP who were not current with CRC. Participants screening viewed a 14 minute multimedia decision aid that addresses CRC screening rationale, recommendations, and options. We conducted an uncontrolled (pre-post) study in which we assessed screening knowledge, self-efficacy, and intent at baseline and immediately after decision aid viewing. We also conducted a follow-up telephone survey ofparticipants at four months to examine rates of patient-provider screening discussions and test completion. Results: Among n = 80 participants, knowledge scores increased from 20% (before) to 72% (after) decision aid viewing (absolute difference [95%CI]: 52% [46, 59]). The proportion with high screening self-efficacy increased from 67% to 92% (25% [13, 37]); the proportion with high screening intent increased from 63% to 95% (32% [21, 44]). We reached 68 (85%) of 80 participants eligible for the follow-up survey. Of these 36 (53%) reported discussing screening with a provider and 13 (19%) completed a test. Conclusion: Viewing a Spanish-language decision aid increased CRC screening knowledge, self-efficacy, and intent among Latinos with LEP. Decision aid viewing appeared to promote both CRC screening discussions with health care providers and test completion. The decision aid may be an effective tool for promoting CRC screening and reducing screening disparities in this population.

Description: Background: Low adherence to chronic kidney disease (CKD) guidelines may be due to unrecognized CKD and lack of guideline awareness on the part of providers. The goal of this study was to evaluate the impact of provider education and a CKD registry on guideline adherence. Methods: We conducted a cluster randomized controlled trial at the Louis Stokes Cleveland VAMC. One of two primary care clinics was randomized to intervention. Providers from both clinics received a lecture on CKD guidelines at study initiation. Providers in the intervention clinic were given access to and shown how to use a CKD registry, which identifies patients with CKD and is automatically updated daily. Eligible patients had at least one primary care visit in the last year, had CKD based on eGFR, and had not received renal replacement therapy. The primary outcome was parathyroid hormone (PTH) adherence, defined by at least one PTH measurement during the 12 month study. Secondary outcomes were measurement of phosphorus, hemoglobin, proteinuria, achievement of goal blood pressure, and treatment with a diuretic or renin-angiotensin system blocker. Results: There were 418 and 363 eligible patients seen during the study in the control and intervention clinics, respectively. Compared to pre-intervention, measurement of PTH increased in both clinics (control clinic: 16% to 23%; intervention clinic: 13% to 28%). Patients in the intervention clinic were more likely to have a PTH measured during the study (adjusted odds ratio = 1.53; 95% CI (1.01, 2.30); P = 0.04). However, the intervention was not associated with a consistent improvement in secondary outcomes. Only 5 of the 37 providers in the intervention clinic accessed the registry. Conclusions: An intervention that included education on CKD guidelines and access to a CKD patient registry marginally improved guideline adherence over education alone. Adherence to the primary process measure improved in both clinics, but no improvement was seen in intermediate clinical outcomes. Improving the care of patients with CKD will likely require a multifaceted approach including system redesign.

Description: Background: Physicians practicing in ambulatory care are adopting electronic health record (EHR) systems. Governments promote this adoption with financial incentives, some hinged on improvements in care. These systems can improve care but most successful systems come from a few highly computerized academic environments. Those findings may not be generalizable to typical ambulatory settings, where evidence of success is largely anecdotal, with little or no use of rigorous methods. The purpose of our pilot study was to evaluate the impact of a diabetes specific chronic disease management system (CDMS) on recording of information pertinent to guideline-concordant diabetes care and to plan for larger, more conclusive studies. Methods: Using a before-after study design we analyzed the medical record of approximately 10 patients from each of 3 diabetes specialists (total = 31) who were seen both before and after the implementation of a CDMS. We used a checklist of key clinical data to compare the completeness of information recorded in the CDMS record to both the clinical note sent to the primary care physician based on that same encounter and the clinical note sent to the primary care physician based on the visit that occurred prior to the implementation of the CDMS, accounting for provider effects with Generalized Estimating Equations. Results: The CDMS record outperformed by a substantial margin dictated notes created for the same encounter. Only 10.1% (95% CI, 7.7% to 12.3%) of the clinically important data were missing from the CDMS chart compared to 25.8% (95% CI, 20.5% to 31.1%) from the clinical note prepared at the time (p

Description: Background: Patients have typically received health care through face-to-face encounters. However, expansion of electronic communication and electronic health records (EHRs) provide alternative means for patient and physicians to interact. Electronic consultations may complement regular healthcare by providing "better, faster, cheaper" processes for diagnosing, treating, and monitoring health conditions. Virtual consultation between physicians may provide a method of streamlining care, potentially saving patients the time and expense of added visits. The purpose of this study was to compare physician usage and patient satisfaction with virtual consultations (VCs) with traditional consultations (TCs) facilitated within an EHR. Methods: We conducted an observational case-control survey study within Kaiser Permanente, Colorado. A sample of patients who had VC requests (N=270) were matched with patients who had TC requests (N=270) by patient age, gender, reason for the consult, and specialty department. These patients (VC and TC), were invited to participate in a satisfaction survey. In addition, 205 primary care physicians who submitted a VC or TC were surveyed. Results: During the study period, 58,146 VC or TC were requested (TC = 96.3%). Patients who completed a satisfaction survey (268 out of 540 patients, 49.6% response rate) indicated they were satisfied with their care, irrespective of the kind of consult (mean 10-point Likert score of 8.5). 88 of 205 primary care physicians surveyed (42.9%) returned at least one survey; VC and TC survey response rates and consulted departments were comparable (p = 0.13). More TCs than VCs requested transfer of patient care (p=0.03), assistance with diagnosis (p = 0.04) or initiating treatment (p =0.04). Within 3 weeks of the consultation request, 72.1% of respondents reported receiving information from VCs, compared with 33.9% of the TCs (p 〈 0.001). Utility of information provided by consultants and satisfaction with consultations did not differ between VCs and TCs. Conclusions: Referring physicians received information from consultants more quickly from VCs compared with TCs, but the value and application of information from both types of consultations were similar. VCs may decrease the need for face-to-face specialty encounters without a decrease in the patient's perception of care.

Description: Background: Advanced mobile communications and portable computation are now combined in handhelddevices called "smartphones", which are also capable of running third-party software. Thenumber of smartphone users is growing rapidly, including among healthcare professionals.The purpose of this study was to classify smartphone-based healthcare technologies asdiscussed in academic literature according to their functionalities, and summarize articles ineach category. Methods: In April 2011, MEDLINE was searched to identify articles that discussed the design,development, evaluation, or use of smartphone-based software for healthcare professionals,medical or nursing students, or patients. A total of 55 articles discussing 83 applications wereselected for this study from 2,894 articles initially obtained from the MEDLINE searches. Results: A total of 83 applications were documented: 57 applications for healthcare professionalsfocusing on disease diagnosis (21), drug reference (6), medical calculators (8), literaturesearch (6), clinical communication (3), Hospital Information System (HIS) client applications(4), medical training (2) and general healthcare applications (7); 11 applications for medicalor nursing students focusing on medical education; and 15 applications for patients focusingon disease management with chronic illness (6), ENT-related (4), fall-related (3), and twoother conditions (2). The disease diagnosis, drug reference, and medical calculatorapplications were reported as most useful by healthcare professionals and medical or nursingstudents. Conclusions: Many medical applications for smartphones have been developed and widely used by healthprofessionals and patients. The use of smartphones is getting more attention in healthcare dayby day. Medical applications make smartphones useful tools in the practice of evidence-basedmedicine at the point of care, in addition to their use in mobile clinical communication. Also,smartphones can play a very important role in patient education, disease self-management,and remote monitoring of patients.

Description: Background: Automated reporting of estimated glomerular filtration rate (eGFR) is a recent advance inlaboratory information technology (IT) that generates a measure of kidney function withchemistry laboratory results to aid early detection of chronic kidney disease (CKD). Becauseaccurate diagnosis of CKD is critical to optimal medical decision-making, several clinicalpractice guidelines have recommended the use of automated eGFR reporting. Since itsintroduction, automated eGFR reporting has not been uniformly implemented by U. S.laboratories despite the growing prevalence of CKD. CKD is highly prevalent within theVeterans Health Administration (VHA), and implementation of automated eGFR reportingwithin this integrated healthcare system has the potential to improve care. In July 2004, theVHA adopted automated eGFR reporting through a system-wide mandate for softwareimplementation by individual VHA laboratories. This study examines the timing of softwareimplementation by individual VHA laboratories and factors associated with implementation. Methods: We performed a retrospective observational study of laboratories in VHA facilities from July2004 to September 2009. Using laboratory data, we identified the status of implementation ofautomated eGFR reporting for each facility and the time to actual implementation from thedate the VHA adopted its policy for automated eGFR reporting. Using survey andadministrative data, we assessed facility organizational characteristics associated withimplementation of automated eGFR reporting via bivariate analyses. Results: Of 104 VHA laboratories, 88% implemented automated eGFR reporting in existinglaboratory IT systems by the end of the study period. Time to initial implementation rangedfrom 0.2 to 4.0years with a median of 1.8years. All VHA facilities with on-site dialysis unitsimplemented the eGFR software (52%, p

Description: Background: Tinnitus is a prevalent and complex medical complaint often co-morbid with stress, anxiety, insomnia, depression, and cognitive or communication difficulties. Its chronicity places a major burden on primary and secondary healthcare services. In our recent national survey of General Practitioners (GPs) from across England, many reported that their awareness of tinnitus was limited and as a result were dissatisfied with the service they currently provide. GPs identified 10 online sources of information they currently use in clinical practice, but welcomed further concise and accurate information on tinnitus assessment and management. The purpose of this study was to assess the content, reliability, and quality of the information related to primary care tinnitus assessment and management on these 10 websites. Methods: Tinnitus related content on each website was assessed using a summative content analysis approach. Reliability and quality of the information was assessed using the DISCERN questionnaire. Results: Quality of information was rated using the validated DISCERN questionnaire. Significant inter-rater reliability was confirmed by Kendall's coefficient of concordance (Wt) which ranged from 0.48 to 0.92 across websites. The website 'Map of Medicine' achieved the highest overall DISCERN score. However, for information on treatment choice, the British Tinnitus Association was rated best. Content analysis revealed that all websites lacked a number of details relating to either tinnitus assessment or management options. Conclusions: No single website provides comprehensive information for GPs, on tinnitus assessment and management and so GPs may need to refer to more than one if they want to maximise their coverage of the topic. From those preferred by GPs we recommend several specific websites as the current 'best' sources. Our findings should guide healthcare website providers to improve the quality and inclusiveness of the information they publish on tinnitus. In the case of one website, our preliminary findings are already doing so. Such developments will in turn help facilitate best practice in primary care.

Description: Background: The purpose of this paper is to illustrate the Elementally Entangled OrganisationalCommunication (EEOC) framework by drawing on a set of three case studies which assessedthe impact of new Health Information Technology (HIT) on a pathology service. The EEOCframework was empirically developed as a tool to tackle organisational communicationchallenges in the implementation and evaluation of health information systems. Methods: The framework was synthesised from multiple research studies undertaken across a majormetropolitan hospital pathology service during the period 2005 to 2008. These studiesevaluated the impact of new HIT systems in pathology departments (Laboratory InformationSystem) and an Emergency Department (Computerised Provider Order Entry) located inSydney, Australia. Results: Key dimensions of EEOC are illustrated by the following case studies: 1) the communicationinfrastructure between the Blood Bank and the ward for the coordination and distribution ofblood products; 2) the organisational environment in the Clinical Chemistry andHaematology departments and their attempts to organise, plan and control the processing oflaboratory specimens; and 3) the temporal make up of the organisation as revealed in changesto the way the Central Specimen Reception allocated, sequenced and synchronised worktasks. Conclusions: The case studies not only highlight the pre-existing communication architecture within theorganisation but also the constitutive role communication plays in the way organisations goabout addressing their requirements. HIT implementation involves a mutual transformation ofthe organisation and the technology. This is a vital consideration because of the dangersassociated with poor organisational planning and implementation of HIT, and the potentialfor unintended adverse consequences, workarounds and risks to the quality and safety ofpatient care. The EEOC framework aims to account for the complex range of contextualfactors and triggers that play a role in the success or otherwise of new HITs, and in therealisation of their innovation potential.

Description: Background: Quality care of type 2 diabetes is complex and requires systematic use of clinical data to monitor care processes and outcomes. An electronic decision support (EDS) tool for the management of type 2 diabetes in primary care was developed by the Australian Pharmaceutical Alliance. The aim of this qualitative study was to evaluate the uptake and use of the EDS tool as well as to describe the impact of the EDS tool on the primary care consultation for diabetes from the perspectives of general practitioners and practice nurses. Methods: This was a qualitative study of telephone interviews. General Practitioners and Practice Nurses from four Divisions of General Practice who had used the EDS tool for a minimum of six weeks were invited to participate. Semi-structured interviews were conducted and the interview transcripts were coded and thematically analysed using NVivo 8 software. Results: In total 15 General Practitioners and 2 Practice Nurses participated. The most commonly used feature of the EDS tool was the summary side bar; its major function was to provide an overview of clinical information and a prompt or reminder to diabetes care. It also assisted communication and served an educational role as a visual aide in the consultation. Some participants thought the tool resulted in longer consultations. There were a range of barriers to use related to the design and functionality of the tool and to the primary care context. Conclusions: The EDS tool shows promise as a way of summarising information about patients' diabetes state, reminder of required diabetes care and an aide to patient education.

Description: Background: Biological signals may carry specific characteristics that reflect basic dynamics of the body. In particular, heart beat signals carry specific signatures that are related to human physiologic mechanisms. In recent years, many researchers have shown that representations which used non-linear symbolic sequences can often reveal much hidden dynamic information. This kind of symbolization proved to be useful for predicting life-threatening cardiac diseases. Methods: This paper presents an improved method called the "Adaptive Interbeat Interval Analysis (AIIA) method". The AIIA method uses the Simple K-Means algorithm for symbolization, which offers a new way to represent subtle variations between two interbeat intervals without human intervention. After symbolization, it uses the n-gram algorithm to generate different kinds of symbolic sequences. Each symbolic sequence stands for a variation phase. Finally, the symbolic sequences are categorized by classic classifiers. Results: In the experiments presented in this paper, AIIA method achieved 91% (3 gram, 26 clusters) accuracy in successfully classifying between the patients with Atrial Fibrillation (AF), Congestive Heart Failure (CHF) and healthy people. It also achieved 87% (3 gram, 26 clusters) accuracy in classifying the patients with apnea. Conclusions: The two experiments presented in this paper demonstrate that AIIA method can categorize different heart diseases. Both experiments acquired the best category results when using the Bayesian Network. For future work, the concept of the AIIA method can be extended to the categorization of other physiological signals. More features can be added to improve the accuracy.

Description: Background: De-identification is a common way to protect patient privacy when disclosing their clinical data for secondary purposes, such as research. One type of attack that de-identification protects against is linking the disclosed patient data with public and semi-public registries. Uniqueness is a commonly used measure of re-identification risk under this attack. If uniqueness can be measured accurately then the risk from this kind of attack can be managed. In practice, it is often not possible to measure uniqueness directly, therefore it must be estimated. Methods: We evaluated the accuracy of uniqueness estimators on clinically relevant data sets. Four candidate estimators were identified because they were evaluated in the past and found to have good accuracy or because they were new and not evaluated comparatively before: the Zayatz estimator, slide negative binomial estimator, Pitman's estimator, and mu-argus. A Monte Carlo simulation was performed to evaluate the uniqueness estimators on six clinically relevant data sets. We varied the sampling fraction and the uniqueness in the population (the value being estimated). The median relative error and inter-quartile range of the uniqueness estimates was measured across 1000 runs. Results: There was no single estimator that performed well across all of the conditions. We developed a decision rule which selected between the Pitman, slide negative binomial and Zayatz estimators depending on the sampling fraction and the difference between estimates. This decision rule had the best consistent median relative error across multiple conditions and data sets. Conclusion: This study identified an accurate decision rule that can be used by health privacy researchers and disclosure control professionals to estimate uniqueness in clinical data sets. The decision rule provides a reliable way to measure re-identification risk.

Description: Background: The aim of this study was to develop a new data-mining model to predict axillary lymph node(AxLN) metastasis in primary breast cancer. To achieve this, we used a decision tree-basedprediction method--the alternating decision tree (ADTree). Methods: Clinical datasets for primary breast cancer patients who underwent sentinel lymph nodebiopsy or AxLN dissection without prior treatment were collected from three institutes(institute A, n = 148; institute B, n = 143; institute C, n = 174) and were used for variableselection, model training and external validation, respectively. The models were evaluatedusing area under the receiver operating characteristics (ROC) curve analysis to discriminatenode-positive patients from node-negative patients. Results: The ADTree model selected 15 of 24 clinicopathological variables in the variable selectiondataset. The resulting area under the ROC curve values were 0.770 [95% confidence interval(CI), 0.689-0.850] for the model training dataset and 0.772 (95% CI: 0.689-0.856) for thevalidation dataset, demonstrating high accuracy and generalization ability of the model. Thebootstrap value of the validation dataset was 0.768 (95% CI: 0.763-0.774). Conclusions: Our prediction model showed high accuracy for predicting nodal metastasis in patients withbreast cancer using commonly recorded clinical variables. Therefore, our model might helponcologists in the decision-making process for primary breast cancer patients before startingtreatment.

Description: Background: Patient-provider communication is a major challenge in resource-limited settings with largecatchment areas. Though mobile phone usership increased 20-fold in Africa over the pastdecade, little is known about acceptability of, perceptions about disclosure andconfidentiality, and preferences for cell phone communication of health information in theregion. Methods: We performed structured interviews of fifty patients at the Immune Suppression Syndromeclinic in Mbarara, Uganda to assess four domains of health-related communication: a) cellphone use practices and literacy, b) preferences for laboratory results communication, c) privacy and confidentiality, and d) acceptability of and preferences for text messaging tonotify patients of abnormal test results. Results: Participants had a median of 38 years, were 56% female, and were residents of a largecatchment area throughout southwestern Uganda. All participants expressed interest in aservice to receive information about laboratory results by cell phone text message, statingbenefits of increased awareness of their health and decreased transportation costs. Ninetypercent reported that they would not be concerned for unintended disclosure. A minorityadditionally expressed concerns about difficulty interpreting messages, discouragement uponlearning bad news, and technical issues. Though all respondents expressed interest inpassword protection of messages, there was also a strong desire for direct messages to limitmisinterpretation of information. Conclusions: Cell phone text messaging for communication of abnormal laboratory results is highlyacceptable in this cohort of HIV-infected patients in rural Uganda. The feasibility of textmessaging, including an optimal balance between privacy and comprehension, should befurther studied.

Description: Background: The purpose of this paper is to examine the acceptability, feasibility, reliability and validity of a new decision quality instrument that assesses the extent to which patients are informed and receive treatments that match their goals. Methods: Cross-sectional mail survey of recent breast cancer survivors, providers and healthy controls and a retest survey of survivors. The decision quality instrument includes knowledge questions and a set of goals, and results in two scores: a breast cancer surgery knowledge score and a concordance score, which reflects the percentage of patients who received treatments that match their goals. Hypotheses related to acceptability, feasibility, discriminant validity, content validity, predictive validity and retest reliability of the survey instrument were examined. Results: We had responses from 440 eligible patients, 88 providers and 35 healthy controls. The decision quality instrument was feasible to implement in this study, with low missing data. The knowledge score had good retest reliability (intraclass correlation coefficient = 0.70) and discriminated between providers and patients (mean difference 35%, p 〈 0.001). The majority of providers felt that the knowledge items covered content that was essential for the decision. Five of the 6 treatment goals met targets for content validity. The five goals had moderate to strong retest reliability (0.64 to 0.87). The concordance score was 89%, indicating that a majority had treatments concordant with that predicted by their goals. Patients who had concordant treatment had similar levels of confidence and regret as those who did not. Conclusions: The decision quality instrument met the criteria of feasibility, reliability, discriminant and content validity in this sample. Additional research to examine performance of the instrument in prospective studies and more diverse populations is needed.

Description: Background: Tools to enhance physician searches of Medline and other bibliographic databases have potential to improve the application of new knowledge in patient care. This is particularly true for articles about glomerular disease, which are published across multiple disciplines and are often difficult to track down. Our objective was to develop and test search filters for PubMed, Ovid Medline, and Embase that allow physicians to search within a subset of the database to retrieve articles relevant to glomerular disease. Methods: We used a diagnostic test assessment framework with development and validation phases. We read a total of 22,992 full text articles for relevance and assigned them to the development or validation set to define the reference standard. We then used combinations of search terms to develop 997,298 unique glomerular disease filters. Outcome measures for each filter included sensitivity, specificity, precision, and accuracy. We selected optimal sensitive and specific search filters for each database and applied them to the validation set to test performance. Results: High performance filters achieved at least 93.8% sensitivity and specificity in the development set. Filters optimized for sensitivity reached at least 96.7% sensitivity and filters optimized for specificity reached at least 98.4% specificity. Performance of these filters was consistent in the validation set and similar among all three databases. Conclusions: PubMed, Ovid Medline, and Embase can be filtered for articles relevant to glomerular disease in a reliable manner. These filters can now be used to facilitate physician searching.

Description: Background: Anesthesia information management system (AIMS) records should be designed andconfigured to facilitate the accurate and prompt recording of multiple drugs administeredcoincidentally or in rapid succession. Methods: We proposed two touch-screen display formats for use with our department's new EPICtouch-screen AIMS. In one format, medication "buttons" were arranged in alphabetical order(i.e. A-C, D-H etc.). In the other, buttons were arranged in categories (Common, Fluids,Cardiovascular, Coagulation etc.). Both formats were modeled on an iPad screen to resemblethe AIMS interface. Anesthesia residents, anesthesiologists, and Certified Registered NurseAnesthetists (n = 60) were then asked to find and touch the correct buttons for a series ofmedications whose names were displayed to the side of the entry screen. The number ofentries made within 2 minutes was recorded. This was done 3 times for each format, with the1st format chosen randomly. Data were analyzed from the third trials with each format tominimize differences in learning. Results: The categorical format had a mean of 5.6 more drugs entered using the categorical method intwo minutes than the alphabetical format (95% confidence interval [CI] 4.5 to 6.8, P

Description: Background: Demographic change with its consequences of an aging society and an increase in thedemand for care in the home environment has triggered intensive research activities in sensordevices and smart home technologies. While many advanced technologies are alreadyavailable, there is still a lack of decision support systems (DSS) for the interpretation of datagenerated in home environments. The aim of the research for this paper is to present the stateof-the-art in DSS for these data, to define characteristic properties of such systems, and todefine the requirements for successful home care DSS implementations. Methods: A literature review was performed along with the analysis of cross-references. Characteristicproperties are proposed and requirements are derived from the available body of literature. Results: 79 papers were identified and analyzed, of which 20 describe implementations of decisioncomponents. Most authors mention server-based decision support components, but only fewpapers provide details about the system architecture or the knowledge base. A list ofrequirements derived from the analysis is presented. Among the primary drawbacks ofcurrent systems are the missing integration of DSS in current health information systemarchitectures including interfaces, the missing agreement among developers with regard tothe formalization and customization of medical knowledge and a lack of intelligentalgorithms to interpret data from multiple sources including clinical application systems. Conclusions: Future research needs to address these issues in order to provide useful information - and notonly large amounts of data - for both the patient and the caregiver. Furthermore, there is aneed for outcome studies allowing for identifying successful implementation concepts.

Description: Background: Several low and middle-income countries are implementing electronic health records (EHR). In the near future, EHRs could become an efficient tool to evaluate healthcare performance if appropriate indicators are developed. The aims of this study are: a) to develop quality of care indicators (QCIs) for type 2 diabetes (T2DM) in the Mexican Institute of Social Security (IMSS) health system; b) to determine the feasibility of constructing QCIs using the IMSS EHR data; and c) to evaluate the quality of care (QC) provided to IMSS patients with T2DM. Methods: We used a three-stage mixed methods approach: a) development of QCIs following the RAND-UCLA method; b) EHR data extraction and construction of indicators; c) QC evaluation using EHR data from 25,130 T2DM patients who received care in 2009. Results: We developed 18 QCIs, of which 14 were possible to construct using available EHR data. QCIs comprised both process of care and health outcomes. Several flaws in the EHR design and quality of data were identified. The indicators of process and outcomes of care suggested areas for improvement. For example, only 13.0% of patients were referred to an ophthalmologist; 3.9% received nutritional counseling; 63.2% of overweight/obese patients were prescribed metformin, and only 23% had HbA1c

Description: Background: Clinical trials are the primary mechanism for advancing clinical care and evidenced-based practice, yet challenges with the recruitment of participants for such trials are widely recognized as a major barrier to these types of studies. Data warehouses store large amounts of heterogenous clinical data that can be used to enhance recruitment practices, but multiple challenges exist when using a data warehouse for such activities, due to the manner of collection, management, integration, analysis, and dissemination of the data. A critical early step in leveraging the DW for recruitment purposes is being able to match trial eligibility criteria to discrete and semi-structured data types in the data warehouse, though trial eligibility criteria tend to be written without concern for their computability. We present the multimodal evaluation of a web-based tool that can be used for prescreening patients for clinical trial eligibility. Results: Clinical trials from the Division of Cardiology and the Department of Family Medicine were used for this multimodal evaluation, which included a validation study, usability study, and a heuristic evaluation. From the results of the validation study, the software demonstrated a positive predictive value (PPV) of 54.12% and 0.007%, respectively, and a negative predictive value (NPV) of 73.3% and 87.5%, respectively, for two types of clinical trials. Heuristic principles concerning error prevention and documentation were characterized as the major usability issues during the heuristic evaluation. Conclusions: This software is intended to provide an initial list of eligible patients to a clinical study coordinators, which provides a starting point for further eligibility screening by the coordinator. Because this software has a high "rule in" ability, meaning that it is able to remove patients who are not eligible for the study, the use of an automated tool built to leverage an existing enterprise DW can be beneficial to determining eligibility and facilitating clinical trial recruitment through prescreening. While the results of this study are promising, further refinement and study of this and related approaches to automated eligibility screening, including comparison to other approaches and stakeholder perceptions, are needed and future studies are planned to address these needs.

Description: Background: Compared with the increasingly widespread use of picture archiving and communicationsystems (PACSs), knowledge concerning users' acceptance of such systems is limited.Knowledge of acceptance is needed given the large (and growing) financial investmentassociated with the implementation of PACSs, and because the level of user acceptanceinfluences the degree to which the benefits of the systems for healthcare can be realized. Methods: A Technology Acceptance Model (TAM) was used to assess the level of acceptance of thehost PACS by staff in the radiology department at King Abdulaziz Medical City (KAMC),Riyadh, Saudi Arabia. A questionnaire survey of 89 PACS users was employed to obtain dataregarding user characteristics, perceived usefulness (PU) (6 items), perceived ease of use(PEU) (4 items), a change construct (4 items), and a behavior (acceptance) construct (9items). Respondents graded each item in each construct using five-point likert scales. Results: Surveyed users reported high levels of PU (4.33/5), PEU (4.15/5), change (4.26/5), andacceptance (3.86/5). The three constructs of PU, PEU, and change explained 41 % of thevariation in PACS user acceptance. PU was the most important predictor, explaining 38 % ofthe variation on its own. The most important single item in the explanatory constructs wasthat users found PACS to have improved the quality of their work in providing better patientcare. Technologists had lower acceptance ratings than did clinicians/radiologists, but noinfluence on acceptance level was found due to gender, age, or length of experience using thePACS. Although not directly measured, there appeared to be no cultural influence on eitherthe level of acceptance or its determinants. Conclusions: User acceptance must be considered when an organization implements a PACS, in order toenhance its successful adoption. Health organizations should adopt a PACS that offers allrequired functions and which is likely to generate high PU on the part of its users, rather thana system that is easy to use. Training/familiarization programs should aim at establishing highlevels of PU in all users, particularly technologists. Health organizations should attempt tomeasure all the factors that influence the acceptance of a PACS by their staff, in order tooptimize the productivity of the system and realize the potential benefits to the greatest extentpossible.

Description: Background: In order to explore the influence of anxiety on decision-making processes, valid anxiety measures are needed. We evaluated a prostate cancer screening (PCS) anxiety scale that measures anxiety related to the prostate-specific antigen (PSA) test, the digital rectal examination (DRE), and the decision to undergo PCS (PCS-D) using two samples in different settings. Methods: We assessed four psychometric properties of the scale using baseline data from a randomized, controlled decision aid trial (n = 301, private clinic; n = 149, public). Results: The 3-factor measure had adequate internal consistency reliability, construct validity, and discriminant validity. Confirmatory factor analyses indicated that the 3-factor model did not have adequate fit. When subscales were considered separately, only the 6-item PCS-D anxiety measure had adequate fit and was invariant across clinics. Conclusions: Our results support the use of a 6-item PCS-D anxiety measure with age-appropriate men in public and private settings. The development of unique anxiety items relating to the PSA test and DRE is still needed.

Description: Background: The successful implementation of decision aids in clinical practice initially depends on how clinicians perceive them. Relatively little is known about the acceptance of decision aids by physicians and factors influencing the implementation of decision aids from their point of view. Our electronic library of decision aids (arriba-lib) is to be used within the encounter and has a modular structure containing evidence-based decision aids for the following topics: cardiovascular prevention, atrial fibrillation, coronary heart disease, oral antidiabetics, conventional and intensified insulin therapy, and unipolar depression. The aim of our study was to evaluate the acceptance of arriba-lib in primary care physicians. Methods: We conducted an evaluation study in which 29 primary care physicians included 192 patients. The physician questionnaire contained information on which module was used, how extensive steps of the shared decision making process were discussed, who made the decision, and a subjective appraisal of consultation length. We used generalised estimation equations to measure associations within patient variables and traditional crosstab analyses. Results: Only a minority of consultations (8.9%) was considered to be unacceptably extended. In 90.6% of consultations, physicians said that a decision could be made. A shared decision was perceived by physicians in 57.1% of consultations. Physicians said that a decision was more likely to be made when therapeutic options were discussed "detailed". Prior experience with decision aids was not a critical variable for implementation within our sample of primary care physicians. Conclusions: Our study showed that it might be feasible to apply our electronic library of decision aids (arriba-lib) in the primary care context. Evidence-based decision aids offer support for physicians in the management of medical information. Future studies should monitor the long-term adoption of arriba-lib in primary care physicians.

Description: Background: The effectiveness of weight loss therapies is commonly measured using body mass index andother obesity-related variables. Although these data are often stored in electronic healthrecords (EHRs) and potentially very accessible, few studies on obesity and weight loss haveused data derived from EHRs. We developed processes for obtaining data from the EHR inorder to construct a database on patients undergoing Roux-en-Y gastric bypass (RYGB)surgery. Methods: Clinical data obtained as part of standard of care in a bariatric surgery program at anintegrated health delivery system were extracted from the EHR and deposited into a datawarehouse. Data files were extracted, cleaned, and stored in research datasets. To illustratethe utility of the data, Kaplan-Meier analysis was used to estimate length of post-operativefollow-up. Results: Demographic, laboratory, medication, co-morbidity, and survey data were obtained from2028 patients who had undergone RYGB at the same institution since 2004. Pre-and postoperativediagnostic and prescribing information were available on all patients, while surveylaboratory data were available on a majority of patients. The number of patients with postoperativelaboratory test results varied by test. Based on Kaplan-Meier estimates, over 74%of patients had post-operative weight data available at 4 years. Conclusion: A variety of EHR-derived data related to obesity can be efficiently obtained and used to studyimportant outcomes following RYGB.

Description: Background: Predictive tools are already being implemented to assist in Emergency Department bed management by forecasting the expected total volume of patients. Yet these tools are unable to detect and diagnose when estimates fall short. Early detection of hotspots, that is subpopulations of patients presenting in unusually high numbers, would help authorities to manage limited health resources and communicate effectively about emerging risks. We evaluate an anomaly detection tool that signals when, and in what way Emergency Departments in 18 hospitals across the state of Queensland, Australia, are significantly exceeding their forecasted patient volumes. Methods: The tool in question is an adaptation of the Surveillance Tree methodology initially proposed in Sparks and Okugami (IntStatl 1:2-24, 2010). for the monitoring of vehicle crashes. The methodology was trained on presentations to 18 Emergency Departments across Queensland over the period 2006 to 2008. Artificial increases were added to simulated, in-control counts for these data to evaluate the tool's sensitivity, timeliness and diagnostic capability. The results were compared with those from a univariate control chart. The tool was then applied to data from 2009, the year of the H1N1 (or 'Swine Flu') pandemic. Results: The Surveillance Tree method was found to be at least as effective as a univariate, exponentially weighted moving average (EWMA) control chart when increases occurred in a subgroup of the monitored population. The method has advantages over the univariate control chart in that it allows for the monitoring of multiple disease groups while still allowing control of the overall false alarm rate. It is also able to detect changes in the makeup of the Emergency Department presentations, even when the total count remains unchanged. Furthermore, the Surveillance Tree method provides diagnostic information useful for service improvements or disease management. Conclusions: Multivariate surveillance provides a useful tool in the management of hospital Emergency Departments by not only efficiently detecting unusually high numbers of presentations, but by providing information about which groups of patients are causing the increase.

Description: Background: Our objective was to develop a model for measuring re-identification risk that more closely mimics the behaviour of an adversary by accounting for repeated attempts at matching and verification of matches, and apply it to evaluate the risk of re-identification for Canada's post-marketing adverse drug event database (ADE).Re-identification is only demonstrably plausible for deaths in ADE. A matching experiment between ADE records and virtual obituaries constructed from Statistics Canada vital statistics was simulated. A new re-identification risk is considered, it assumes that after gathering all the potential matches for a patient record (all records in the obituaries that are potential matches for an ADE record), an adversary tries to verify these potential matches. Two adversary scenarios were considered: (a) a mildly motivated adversary who will stop after one verification attempt, and (b) a highly motivated adversary who will attempt to verify all the potential matches and is only limited by practical or financial considerations. Methods: The mean percentage of records in ADE that had a high probability of being re-identified was computed. Results: Under scenario (a), the risk of re-identification from disclosing the province, age at death, gender, and exact date of the report is quite high, but the removal of province brings down the risk significantly. By only generalizing the date of reporting to month and year and including all other variables, the risk is always low. All ADE records have a high risk of re-identification under scenario (b), but the plausibility of that scenario is limited because of the financial and practical deterrent even for highly motivated adversaries. Conclusions: It is possible to disclose Canada's adverse drug event database while ensuring that plausible re-identification risks are acceptably low. Our new re-identification risk model is suitable for such risk assessments.

Description: Background: A medical tests may influence the health of patients by guiding clinical decisions, such as treatment in case of a positive test result. However, a medical test can influence the health of patients through other mechanisms as well, like giving reassurance. To make a clinical recommendation about a medical test, we should be aware of the full range of effects of that test on patients. This requires an understanding of the range of effects that medical testing can have on patients. This study evaluates the mechanisms through which medical testing can influence patients' health, other than the effect on clinical management, from a gynecologists' perspective. Methods: A qualitative study in which explorative focus groups were conducted with gynecologists, gynecological residents and gynecological M.D. researchers (n = 43). Discussions were transcribed verbatim. Transcriptions were coded inductively and analyzed by three researchers. Results: All participants contributed various clinical examples in which medical testing had influenced patients' health. Clinical examples illustrated that testing, in itself or in interaction with contextual factors, may provoke a wide range of effects on patients. Our data showed that testing can influence the doctor's perceptions of the patients' appraisal of their illness, their perceived control, or the doctor-patient relationship. This may lead to changes in psychological, behavioral, and/or medical outcomes, both favorably or unfavorably. The data were used to construct a conceptual framework of effects of medical testing on patients. Conclusions: Besides supporting clinical decision making, medical testing may have favorable or unfavorable effects on patients' health though several mechanisms.

Description: Background: Studying rare outcomes, new interventions and diverse populations often requires collaborations across multiple health research partners. However, transferring healthcare research data from one institution to another can increase the risk of data privacy and security breaches. Methods: A working group of multi-site research programmers evaluated the need for tools to support data security and data privacy. The group determined that data privacy support tools should: 1) allow for a range of allowable Protected Health Information (PHI); 2) clearly identify what type of data should be protected under the Health Insurance Portability and Accountability Act (HIPAA); and 3) help analysts identify which protected health information data elements are allowable in a given project and how they should be protected during data transfer. Based on these requirements we developed two performance support tools to support data programmers and site analysts in exchanging research data. Results: The first tool, a workplan template, guides the lead programmer through effectively communicating the details of multi-site programming, including how to run the program, what output the program will create, and whether the output is expected to contain protected health information. The second performance support tool is a checklist that site analysts can use to ensure that multi-site program output conforms to expectations and does not contain protected health information beyond what is allowed under the multi-site research agreements. Conclusions: Together the two tools create a formal multi-site programming workflow designed to reduce the chance of accidental PHI disclosure.

Description: Background: Internationally, generic medicines are increasingly seen as a key strategy to reduce healthcare expenditure, therefore awareness and knowledge transfer regarding generic medicines are valid areas of research. Although the Internet is a frequently used source of medical information, the accuracy of material found online is variable. The aim of this study was to evaluate information provided on the Internet regarding generic medicines in terms of quality of information and readability. Methods: Internet searches for information regarding generic medicine were completed, with a pre-defined search term, using the Google search engine, in five English-speaking geographical regions (US, UK, Ireland, Canada and Australia). Search results likely to be looked at by a searcher were collated and assessed for the quality of generic medicine-related information in the websites, using a novel customised Website Quality Assessment (WQA) tool; and for readability, using existing methods. The reproducibility of the tools between two independent reviewers was evaluated and correlations between WQA score, readability statistics and Google search engine results page ranking were assessed. Results: Wikipedia was the highest-ranking search result in 100% of searches performed. Considerable variability of search results returned between different geographical regions was observed, including that websites identified in the Australian search generated the highest number of country specific websites; searches performed using computers with Irish, British, American and Canadian IP addresses appear to be more similar to each other than the google.com search performed in Australia; and the Canadian google.ca results show a notable difference from any of the other searches. Of the 24 websites assessed, none scored a perfect WQA score. Notably, strong correlation was seen between WQA and readability scores and ranking on google.com search results. Conclusions: This novel evaluation of websites providing information on generic medicines showed that, of the websites likely to be seen by a searcher, none demonstrated a combination of scoring highly on quality of information (as evinced by WQA score) and readability. Therefore, there is a gap in online knowledge provision on this topic which, if filled by a website designed using the WQA tool developed in this study, has an improved likelihood of ranking highly in google.com search results.

Description: Background: Conjoint Analysis (CA) can serve as an important tool to study health disparities and unique factors underlying decision-making in diverse subgroups. However, methodological advancements are needed in exploiting this application of CA. We compared the internal and external predictive validity and inter-temporal stability of Choice-based-Conjoint (CBC) analysis between African-Americans and Whites in the clinical context of preferences for analgesic treatment for cancer pain. Methods: We conducted a prospective study with repeated-measures at two time-points (T1 = baseline; T2 = 3-months). African-Americans (n = 102); and Whites (n = 139) with cancer-related pain were recruited from outpatient oncology clinics in Philadelphia. Informed by pilot work, a computer-assisted CBC experiment was developed using 5 attributes of analgesic treatment: type of analgesic; expected pain relief; type of side-effects; severity of side-effects; and out-of-pocket cost. The design included 2 choice alternatives, 12 random tasks, 2 holdout tasks, and maximum of 6 levels per attribute. The internal and external predictive validity of CBC was estimated using Root Likelihood (RLH) and Mean Absolute Error (MAE), respectively. Inter-temporal stability was assessed using Cohen's kappa. Results: Whites predominantly traded based on "pain relief" whereas African-Americans traded based on "type of side-effects". At both time-points, the internal validity (RLH) was slightly higher for Whites than for African-Americans. The RLH for African-Americans improved at T2, possibly due to the learning effect. Lexicographic (dominant) behavior was observed in 29% of choice datasets; Whites were more likely than African-Americans to engage in a lexicographic behavior (60% vs. 40%). External validity (MAE) was slightly better for African-Americans than for Whites at both time-points (MAE: T1 = 3.04% for African-Americans and 4.02% for Whites; T2 = 8.04% for African-Americans; 10.24% for Whites). At T2, the MAE increased for both groups possibly reflecting an increase in the complexity of pain treatment decision-making based on expectations (T1) as opposed to reality (T2). The inter-temporal stability was fair for CBC attributes between T1 and T2 (kappa = 0.28, 95% CI: 0.24-0.32) and was not predicted by demographics including race. Conclusions: While we found slight group differences, overall the internal and external predictive validity of CBC was comparable between African-Americans and Whites. We discuss some areas to investigate and improve internal and external predictive validity of CBC experiments.

Description: Background: The objective was to find evidence to substantiate assertions that electronic applications for medication management in ambulatory care (electronic prescribing, clinical decision support (CDSS), electronic health record, and computer generated paper prescriptions), while intended to reduce prescribing errors, can themselves result in errors that might harm patients or increase risks to patient safety. Methods: Because a scoping search for adverse events in randomized controlled trials (RCTs) yielded few relevant results, we systematically searched nine databases, including MEDLINE, EMBASE, and The Cochrane Database of Systematic Reviews for systematic reviews and studies of a wide variety of designs that reported on implementation of the interventions. Studies that had safety and adverse events as outcomes, monitored for them, reported anecdotally adverse events or other events that might indicate a threat to patient safety were included. Results: We found no systematic reviews that examined adverse events or patient harm caused by organizational interventions. Of the 4056 titles and abstracts screened, 176 full-text articles were assessed for inclusion. Sixty-one studies with appropriate interventions, settings and participants but without patient safety, adverse event outcomes or monitoring for risks were excluded, along with 77 other non-eligible studies. Eighteen randomised controlled trials (RCTs), 5 non-randomised controlled trials (non-R, CTs) and 15 observational studies were included. The most common electronic intervention studied was CDSS and the most frequent clinical area was cardio-vascular, including anti-coagulants. No RCTS or non-R,CTS reported adverse event. Adverse events reported in observational studies occurred less frequently after implementation of CDSS. One RCT and one observational study reported an increase in problematic prescriptions with electronic prescribing Conclusions: The safety implications of electronic medication management in ambulatory care have not been established with results from studies found in this systematic review. Only a minority of studies that investigated these interventions included threats to patients' safety as outcomes or monitored for adverse events. It is therefore not surprising that we found little evidence to substantiate fears of new risks to patient safety with their implementation. More research is needed to focus on the draw-backs and negative outcomes that implementation of these interventions might introduce.

Description: Background: The necessity to translate eligibility criteria from free text into decision rules that are compatible with data from the electronic health record (EHR) constitutes the main challenge when developing and deploying clinical trial recruitment support systems. Recruitment decisions based on case-based reasoning, i.e. using past cases rather than explicit rules, could dispense with the need for translating eligibility criteria and could also be implemented largely independently from the terminology of the EHR's database. We evaluated the feasibility of predictive modeling to assess the eligibility of patients for clinical trials and report on a prototype's performance for different system configurations. Methods: The prototype worked by using existing basic patient data of manually assessed eligible and ineligible patients to induce prediction models. Performance was measured retrospectively for three clinical trials by plotting receiver operating characteristic curves and comparing the area under the curve (ROC-AUC) for different prediction algorithms, different sizes of the learning set and different numbers and aggregation levels of the patient attributes. Results: Random forests were generally among the best performing models with a maximum ROC-AUC of 0.81 (CI: 0.72-0.88) for trial A, 0.96 (CI: 0.95-0.97) for trial B and 0.99 (CI: 0.98-0.99) for trial C. The full potential of this algorithm was reached after learning from approximately 200 manually screened patients (eligible and ineligible). Neither block- nor category-level aggregation of diagnosis and procedure codes influenced the algorithms' performance substantially. Conclusions: Our results indicate that predictive modeling is a feasible approach to support patient recruitment into clinical trials. Its major advantages over the commonly applied rule-based systems are its independency from the concrete representation of eligibility criteria and EHR data and its potential for automation.

Description: Background: Robust, extensible and distributed databases integrating clinical, imaging and molecular datarepresent a substantial challenge for modern neuroscience. It is even more difficult to provideextensible software environments able to effectively target the rapidly changing data requirementsand structures of research experiments. There is an increasing request from the neurosciencecommunity for software tools addressing technical challenges about: (i) supporting researchers in themedical field to carry out data analysis using integrated bioinformatics services and tools; (ii)handling multimodal/multiscale data and metadata, enabling the injection of several different datatypes according to structured schemas; (iii) providing high extensibility, in order to address differentrequirements deriving from a large variety of applications simply through a user runtimeconfiguration. Methods: A dynamically extensible data structure supporting collaborative multidisciplinary research projectsin neuroscience has been defined and implemented. We have considered extensibility issues fromtwo different points of view. First, the improvement of data flexibility has been taken into account.This has been done through the development of a methodology for the dynamic creation and use ofdata types and related metadata, based on the definition of "meta" data model. This way, users arenot constrainted to a set of predefined data and the model can be easily extensible and applicable todifferent contexts. Second, users have been enabled to easily customize and extend the experimentalprocedures in order to track each step of acquisition or analysis. This has been achieved through aprocess-event data structure, a multipurpose taxonomic schema composed by two generic mainobjects: events and processes. Then, a repository has been built based on such data model andstructure, and deployed on distributed resources thanks to a Grid-based approach. Finally, dataintegration aspects have been addressed by providing the repository application with an efficientdynamic interface designed to enable the user to both easily query the data depending on defineddatatypes and view all the data of every patient in an integrated and simple way. Results: The results of our work have been twofold. First, a dynamically extensible data model has beenimplemented and tested based on a "meta" data-model enabling users to define their own data typesindependently from the application context. This data model has allowed users to dynamicallyinclude additional data types without the need of rebuilding the underlying database. Then a complexprocess-event data structure has been built, based on this data model, describing patient-centereddiagnostic processes and merging information from data and metadata. Second, a repositoryimplementing such a data structure has been deployed on a distributed Data Grid in order to providescalability both in terms of data input and data storage and to exploit distributed data andcomputational approaches in order to share resources more efficiently. Moreover, data managing hasbeen made possible through a friendly web interface. The driving principle of not being forced topreconfigured data types has been satisfied. It is up to users to dynamically configure the data modelfor the given experiment or data acquisition program, thus making it potentially suitable forcustomized applications. Conclusions: Based on such repository, data managing has been made possible through a friendly web interface.The driving principle of not being forced to preconfigured data types has been satisfied. It is up tousers to dynamically configure the data model for the given experiment or data acquisition program,thus making it potentially suitable for customized applications.

Description: Background: Smartphone usage has spread to many settings including that of healthcare with numerous potential and realised benefits. The ability to download custom-built software applications (apps) has created a new wealth of clinical resources available to healthcare staff, providing evidence-based decisional tools to reduce medical errors.Previous literature has examined how smartphones can be utilised by both medical student and doctor populations, to enhance educational and workplace activities, with the potential to improve overall patient care. However, this literature has not examined smartphone acceptance and patterns of medical app usage within the student and junior doctor populations. Methods: An online survey of medical student and foundation level junior doctor cohorts was undertaken within one United Kingdom healthcare region. Participants were asked whether they owned a Smartphone and if they used apps on their Smartphones to support their education and practice activities. Frequency of use and type of app used was also investigated. Open response questions explored participants' views on apps that were desired or recommended and the characteristics of apps that were useful. Results: 257 medical students and 131 junior doctors responded, equating to a response rate of 15.0% and 21.8% respectively. 79.0% (n=203/257) of medical students and 74.8% (n=98/131) of junior doctors owned a smartphone, with 56.6% (n=115/203) of students and 68.4% (n=67/98) of doctors owning an iPhone.The majority of students and doctors owned 1--5 medical related applications, with very few owning more than 10, and iPhone owners significantly more likely to own apps (Chi sq, p

Description: Background: Cloud-based desktop virtualization infrastructure (VDI) is known as providing simplified management of application and desktop, efficient management of physical resources, and rapid service deployment, as well as connection to the computer environment at anytime, anywhere with anydevice. However, the economic validity of investing in the adoption of the system at a hospital has not been established. Methods: This study computed the actual investment cost of the hospital-wide VDI implementation at the 910-bed Seoul National University Bundang Hospital in Korea and the resulting effects (i.e., reductions in PC errors and difficulties, application and operating system update time, and account management time). Return on investment (ROI), net present value (NPV), and internal rate of return (IRR) indexes used for corporate investment decision-making were used for the economic analysis of VDI implementation. Results: The results of five-year cost-benefit analysis given for 400 Virtual Machines (VMs; i.e., 1,100 users in the case of SNUBH) showed that the break-even point was reached in the fourth year of the investment. At that point, the ROI was 122.6%, the NPV was approximately US$192,000, and the IRR showed an investment validity of 10.8%. From our sensitivity analysis to changing the number of VMs (in terms of number of users), the greater the number of adopted VMs was the more investable the system was. Conclusions: This study confirms that the emerging VDI can have an economic impact on hospital information system (HIS) operation and utilization in a tertiary hospital setting.

Description: Background: Sexually transmitted diseases (STDs), especially the Chlamydia trachomatis bacterial infection, a common cause of infertility, are highly prevalent in developed countries, and a worrying problem in North Norway, where the incidence of chlamydia twice the Norwegian average. Seventy percent of reported chlamydia cases are found in people below 25 years of age, and although its spread could be controlled with proper prevention, young people are more aware of the risks of unwanted pregnancy than their risk of acquiring a STD. Information and Communication Technologies, including, the Internet, social media and/or smartphones, should be valued for sexual health promotion for their potential to engage young audiences. And in these media, avatars guarantee anonymity to users when handling sensitive information. The main objective of this project is to achieve that North Norwegian youngsters become more aware of STDs through the use of popular technologies among young people. Methods: A Virtual Clinic for Sexually Transmitted Diseases (VCSTD) will be developed. The VCSTD will provide early guidance and reliable information sources concerning reproductive health, delivered in a novel and innovative way to the younger population. The VCSTD consists of an "avatar" supported intervention in a serious gamming and e-learning environment, which will bypass direct physical access (in person) to reliable medical information, as well as allowing the youngsters to share that information in social media, and thus helping the VCSTD to be disseminated to more people.Data analyses will be conducted on publically available health data relevant to STDs in Troms and Finnmark, like the absolute number of chlamydia tests, the amount of emergency contraception medication sold, and the number of abortions. Also, usage data of the system and experiences of usefulness will be explored through participants' voluntary responses to a feedback form available in the VCSTD.DiscussionThis study will examine the usefulness of an online public health intervention that aims to promote healthy sexual practices among North-Norwegian youngsters. If shown to be effective, the intervention could prove to be an affordable and widely accessible intervention to decrease risky sexual practices in younger population.

Description: Background: To determine the behavior of physicians regarding medical literature reading andparticipation in research activities at one of the largest teaching hospitals in Pakistan.MethodThis descriptive, cross-sectional study was conducted by interviewing the house officers,residents and fellows of six major specialties (Medicine, Surgery, Pediatrics, Psychology,Obstetrics & Gynecology and Anesthesia) in Civil Hospital Karachi between August andDecember, 2011. The questionnaire elicited responses regarding the reading habits ofphysicians, preferred sources of information, their participation in research publications andresearch supervision and views regarding journal club. SPSS 17.0 was used for data entry andanalysis.ResultA total of 259 completely filled questionnaires were returned with a response rate of 85.19%.Mean age of the participants was 29.67 +/- 7.65 years. Books were selected by 71.4% doctorsas their preferred source of information, regardless of their clinical specialties. (p 〈 0.05). Ejournalswere preferred by 75.7% of the doctors over printed journals. This holds true fordoctors from all specialties (p 〈 0.05). The ease of searching for relevant articles was themajor contributor (50.5%) in preference of e-journals. 137 (52.9%) doctors read 5 or lessarticles per week. 30 (11.6%) doctors have subscription of journals (printed or electronic). Atleast one research paper has been published by 151 (58.3%) of the physicians interviewed.Most common reason for not participating in research activities was busy schedule (56.4%).Almost half (49.4%) doctors reported lack of journal club in their units. Of these, majority88.3% wanted a journal club in their respective units. Conclusion: Urgent intervention is required to promote healthcare literature reading and writing practicein our physicians. Easy access to workplace computers with internet and subscription of paidjournals will facilitate physicians. Lack of supervisors and busy schedule were reported to beimportant contributors for not participating in research. Addressing these issues willencourage doctors to participate more in research activities.