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Chiem JL, Hansen EE, Fernandez N, Merguerian PA, Parikh SR, Reece K, Low DK, Martin LD. Transforming into a Learning Health System: A Quality Improvement Initiative. Pediatr Qual Saf 2024; 9:e724. [PMID: 38751896 PMCID: PMC11093568 DOI: 10.1097/pq9.0000000000000724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 02/21/2024] [Indexed: 05/18/2024] Open
Abstract
Background The Institute of Medicine introduced the Learning Healthcare System concept in 2006. The system emphasizes quality, safety, and value to improve patient outcomes. The Bellevue Clinic and Surgical Center is an ambulatory surgical center that embraces continuous quality improvement to provide exceptional patient-centered care to the pediatric surgical population. Methods We used statistical process control charts to study the hospital's electronic health record data. Over the past 7 years, we have focused on the following areas: efficiency (surgical block time use), effectiveness (providing adequate analgesia after transitioning to an opioid-sparing protocol), efficacy (creating a pediatric enhanced recovery program), equity (evaluating for racial disparities in surgical readmission rates), and finally, environmental safety (tracking and reducing our facility's greenhouse gas emissions from inhaled anesthetics). Results We have seen improvement in urology surgery efficiency, resulting in a 37% increase in monthly surgical volume, continued adaptation to our opioid-sparing protocol to further reduce postanesthesia care unit opioid administration for tonsillectomy and adenoidectomy cases, successful implementation of an enhanced recovery program, continued work to ensure equitable healthcare for our patients, and more than 85% reduction in our facility's greenhouse gas emissions from inhaled anesthetics. Conclusions The Bellevue Clinic and Surgical Center facility is a living example of a learning health system, which has evolved over the years through continued patient-centered QI work. Our areas of emphasis, including efficiency, effectiveness, efficacy, equity, and environmental safety, will continue to impact the community we serve positively.
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Affiliation(s)
- Jennifer L. Chiem
- From the Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, Seattle, Wash
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Wash
| | - Elizabeth E. Hansen
- From the Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, Seattle, Wash
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Wash
| | - Nicolas Fernandez
- Department of Urology, Seattle Children’s Hospital, Seattle, Wash
- Department of Urology, University of Washington, Seattle, Wash
| | - Paul A. Merguerian
- Department of Urology, Seattle Children’s Hospital, Seattle, Wash
- Department of Urology, University of Washington, Seattle, Wash
| | - Sanjay R. Parikh
- Seattle Children’s Hospital, Seattle, Wash
- Department of Otolaryngology—Head and Neck Surgery, University of Washington, Seattle, Wash
| | - Kayla Reece
- Department of Perioperative Services, Seattle Children’s Hospital, Seattle, Wash
| | - Daniel K. Low
- From the Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, Seattle, Wash
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Wash
| | - Lynn D. Martin
- From the Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, Seattle, Wash
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Wash
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Carr SG, Clifton JC, Freundlich RE, Fowler LC, Sherwood ER, McEvoy MD, Robertson A, Dunworth B, McCarthy KY, Shotwell MS, Kertai MD. Improving Neuromuscular Monitoring Through Education-Based Interventions and Studying Its Association With Adverse Postoperative Outcomes: A Retrospective Observational Study. Anesth Analg 2024; 138:517-529. [PMID: 38364243 PMCID: PMC10878712 DOI: 10.1213/ane.0000000000006722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
BACKGROUND We assessed the association between education-based interventions, the frequency of train-of-four (TOF) monitoring, and postoperative outcomes. METHODS We studied adults undergoing noncardiac surgery from February 1, 2020 through October 31, 2021. Our education-based interventions consisted of 3 phases. An interrupted time-series analysis, adjusting for patient- and procedure-related characteristics and secular trends over time, was used to assess the associations between education-based interventions and the frequency of TOF monitoring, postoperative pulmonary complications (PPCs), 90-day mortality, and sugammadex dosage. For each outcome and intervention phase, we tested whether the intervention at that phase was associated with an immediate change in the outcome or its trend (weekly rate of change) over time. In a sensitivity analysis, the association between education-based interventions and postoperative outcomes was adjusted for TOF monitoring. RESULTS Of 19,422 cases, 11,636 (59.9%) had documented TOF monitoring. Monitoring frequency increased from 44.2% in the first week of preintervention stage to 83.4% in the final week of the postintervention phase. During the preintervention phase, the odds of TOF monitoring trended upward by 0.5% per week (odds ratio [OR], 1.005; 95% confidence interval [CI], 1.002-1.007). Phase 1 saw an immediate 54% increase (OR, 1.54; 95% CI, 1.33-1.79) in the odds, and the trend OR increased by 3% (OR, 1.03; 95% CI, 1.01-1.05) to 1.035, or 3.5% per week (joint Wald test, P < .001). Phase 2 was associated with a further immediate 29% increase (OR, 1.29; 95% CI, 1.02-1.64) but no significant association with trend (OR, 0.96; 95% CI, 0.93-1.01) of TOF monitoring (joint test, P = .04). Phase 3 and postintervention phase were not significantly associated with the frequency of TOF monitoring (joint test, P = .16 and P = .61). The study phases were not significantly associated with PPCs or sugammadex administration. The trend OR for 90-day mortality was larger by 24% (OR, 1.24; 95% CI, 1.06-1.45; joint test, P = .03) in phase 2 versus phase 1, from a weekly decrease of 8% to a weekly increase of 14%. However, this trend reversed again at the transition from phase 3 to the postintervention phase (OR, 0.82; 95% CI, 0.68-0.99; joint test, P = .05), from a 14% weekly increase to a 6.2% weekly decrease in the odds of 90-day mortality. In sensitivity analyses, adjusting for TOF monitoring, we found similar associations between study initiatives and postoperative outcomes. TOF monitoring was associated with lower odds of PPCs (OR, 0.69; 95% CI, 0.55-0.86) and 90-day mortality (OR, 0.79; 95% CI, 0.63-0.98), but not sugammadex dosing (mean difference, -0.02; 95% CI, -0.04 to 0.01). CONCLUSIONS Our education-based interventions were associated with both TOF utilization and 90-day mortality but were not associated with either the odds of PPCs or sugammadex dosing. TOF monitoring was associated with reduced odds of PPCs and 90-day mortality.
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Affiliation(s)
- Shane G. Carr
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Jacob C. Clifton
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert E. Freundlich
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Leslie C. Fowler
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edward R. Sherwood
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew D. McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amy Robertson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brent Dunworth
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Karen Y. McCarthy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew S. Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Miklos D. Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Ahmed T, Stinson K, Johnson J, Latif Z. QuizTime: Innovative Learning Platform to Support Just-In-Time Asynchronous Quizzes to Improve Health Outcomes. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2024; 2023:253-260. [PMID: 38222381 PMCID: PMC10785841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
QuizTime is an innovative, asynchronous, spaced learning platform that provides just-in-time learning to increase knowledge and retention. QuizTime was created in 2015, and since then, its effectiveness has been tested and studied across multiple healthcare learning interventions. This paper describes the importance of spaced learning in knowledge acquisition and retention, and the motivation behind the creation of the innovative QuizTime platform. We demonstrate the usefulness of this platform, as shown by multiple case studies using QuizTime, to increase and engage medical students, residents, physicians and health care providers with new quizzes and interventions.
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Affiliation(s)
- Toufeeq Ahmed
- Vanderbilt University Medical Center, Nashville, TN, United States
| | - Katie Stinson
- Vanderbilt University Medical Center, Nashville, TN, United States
| | - Jay Johnson
- Vanderbilt University Medical Center, Nashville, TN, United States
| | - Zainab Latif
- Vanderbilt University Medical Center, Nashville, TN, United States
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Santapuram P, Coker Fowler L, Garvey KV, McEvoy MD, Robertson A, Dunworth B, McCarthy K, Freundlich R, Allen BFS, Kertai MD. Improving Compliance With Institutional Performance on Train of Four Monitoring. THE JOURNAL OF EDUCATION IN PERIOPERATIVE MEDICINE : JEPM 2023; 25:E698. [PMID: 36960031 PMCID: PMC10029113 DOI: 10.46374/volxxv_issue1_kertai] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
BACKGROUND We performed a multistep quality improvement project related to neuromuscular blockade and monitoring to evaluate the effectiveness of a comprehensive quality improvement program based upon the Multi-institutional Perioperative Outcomes Group (MPOG) Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) metrics targeted specifically at improving train of four (TOF) monitoring rates. METHODS We adapted the plan-do-study-act (PDSA) framework and implemented 2 PDSA cycles between January 2021 and December 2021. PDSA Cycle 1 (Phase I) and PDSA Cycle 2 (Phase II) included a multipart program consisting of (1) a departmental survey assessing attitudes toward intended results, outcomes, and barriers for TOF monitoring, (2) personalized MPOG ASPIRE quality performance reports displaying provider performance, (3) a dashboard access to help providers complete a case-by-case review, and (4) a web-based app spaced education module concerning TOF monitoring and residual neuromuscular blockade. Our primary outcome was to identify the facilitators and barriers to implementation of our intervention aimed at increasing TOF monitoring. RESULTS In Phase I, 25 anesthesia providers participated in the preintervention and postintervention needs assessment survey and received personalized quality metric reports. In Phase II, 222 providers participated in the preintervention needs assessment survey and 201 participated in the postintervention survey. Thematic analysis of Phase I survey data aimed at identifying the facilitators and barriers to implementation of a program aimed at increasing TOF monitoring revealed the following: intended results were centered on quality of patient care, barriers to implementation largely encompassed issues with technology/equipment and the increased burden placed on providers, and important outcomes were focused on patient outcomes and improving provider knowledge. Results of Phase II survey data was similar to that of Phase I. Notably in Phase II a few additional barriers to implementation were mentioned including a fear of loss of individualization due to standardization of patient care plan, differences between the attending overseeing the case and the in-room provider who is making decisions/completing documentation, and the frequency of intraoperative handovers. Compared to preintervention, postintervention compliance with TOF monitoring increased from 42% to 70% (28% absolute difference across N = 10 169 cases; P < .001). CONCLUSIONS Implementation of a structured quality improvement program using a novel educational intervention showed improvements in process metrics regarding neuromuscular monitoring, while giving us a better understanding of how best to implement improvements in this metric at this magnitude.
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Affiliation(s)
- Pooja Santapuram
- Pooja Santapuram is an Anesthesiology Resident at Columbia University in New York, NY
| | - Leslie Coker Fowler
- The following authors are in the Department of Anesthesiology at Vanderbilt University Medical Center, in Nashville, TN: Leslie Coker Fowler is an Assistant Professor; Kim V. Garvey is a Research Instructor; Matthew D. McEvoy is a Professor; Amy Robertson is an Associate Professor; Brent Dunworth is an Associate Nurse Executive; Karen McCarthy is a Senior Database Administrator; Robert Freundlich is an Associate Professor; Brian F. S. Allen is an Associate Professor; Miklos D. Kertai is a Professor
| | - Kim V. Garvey
- The following authors are in the Department of Anesthesiology at Vanderbilt University Medical Center, in Nashville, TN: Leslie Coker Fowler is an Assistant Professor; Kim V. Garvey is a Research Instructor; Matthew D. McEvoy is a Professor; Amy Robertson is an Associate Professor; Brent Dunworth is an Associate Nurse Executive; Karen McCarthy is a Senior Database Administrator; Robert Freundlich is an Associate Professor; Brian F. S. Allen is an Associate Professor; Miklos D. Kertai is a Professor
| | - Matthew D. McEvoy
- The following authors are in the Department of Anesthesiology at Vanderbilt University Medical Center, in Nashville, TN: Leslie Coker Fowler is an Assistant Professor; Kim V. Garvey is a Research Instructor; Matthew D. McEvoy is a Professor; Amy Robertson is an Associate Professor; Brent Dunworth is an Associate Nurse Executive; Karen McCarthy is a Senior Database Administrator; Robert Freundlich is an Associate Professor; Brian F. S. Allen is an Associate Professor; Miklos D. Kertai is a Professor
| | - Amy Robertson
- The following authors are in the Department of Anesthesiology at Vanderbilt University Medical Center, in Nashville, TN: Leslie Coker Fowler is an Assistant Professor; Kim V. Garvey is a Research Instructor; Matthew D. McEvoy is a Professor; Amy Robertson is an Associate Professor; Brent Dunworth is an Associate Nurse Executive; Karen McCarthy is a Senior Database Administrator; Robert Freundlich is an Associate Professor; Brian F. S. Allen is an Associate Professor; Miklos D. Kertai is a Professor
| | - Brent Dunworth
- The following authors are in the Department of Anesthesiology at Vanderbilt University Medical Center, in Nashville, TN: Leslie Coker Fowler is an Assistant Professor; Kim V. Garvey is a Research Instructor; Matthew D. McEvoy is a Professor; Amy Robertson is an Associate Professor; Brent Dunworth is an Associate Nurse Executive; Karen McCarthy is a Senior Database Administrator; Robert Freundlich is an Associate Professor; Brian F. S. Allen is an Associate Professor; Miklos D. Kertai is a Professor
| | - Karen McCarthy
- The following authors are in the Department of Anesthesiology at Vanderbilt University Medical Center, in Nashville, TN: Leslie Coker Fowler is an Assistant Professor; Kim V. Garvey is a Research Instructor; Matthew D. McEvoy is a Professor; Amy Robertson is an Associate Professor; Brent Dunworth is an Associate Nurse Executive; Karen McCarthy is a Senior Database Administrator; Robert Freundlich is an Associate Professor; Brian F. S. Allen is an Associate Professor; Miklos D. Kertai is a Professor
| | - Robert Freundlich
- The following authors are in the Department of Anesthesiology at Vanderbilt University Medical Center, in Nashville, TN: Leslie Coker Fowler is an Assistant Professor; Kim V. Garvey is a Research Instructor; Matthew D. McEvoy is a Professor; Amy Robertson is an Associate Professor; Brent Dunworth is an Associate Nurse Executive; Karen McCarthy is a Senior Database Administrator; Robert Freundlich is an Associate Professor; Brian F. S. Allen is an Associate Professor; Miklos D. Kertai is a Professor
| | - Brian F. S. Allen
- The following authors are in the Department of Anesthesiology at Vanderbilt University Medical Center, in Nashville, TN: Leslie Coker Fowler is an Assistant Professor; Kim V. Garvey is a Research Instructor; Matthew D. McEvoy is a Professor; Amy Robertson is an Associate Professor; Brent Dunworth is an Associate Nurse Executive; Karen McCarthy is a Senior Database Administrator; Robert Freundlich is an Associate Professor; Brian F. S. Allen is an Associate Professor; Miklos D. Kertai is a Professor
| | - Miklos D. Kertai
- The following authors are in the Department of Anesthesiology at Vanderbilt University Medical Center, in Nashville, TN: Leslie Coker Fowler is an Assistant Professor; Kim V. Garvey is a Research Instructor; Matthew D. McEvoy is a Professor; Amy Robertson is an Associate Professor; Brent Dunworth is an Associate Nurse Executive; Karen McCarthy is a Senior Database Administrator; Robert Freundlich is an Associate Professor; Brian F. S. Allen is an Associate Professor; Miklos D. Kertai is a Professor
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Collard HR, Grumbach K. A Call to Improve Health by Achieving the Learning Health Care System. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:29-35. [PMID: 36006840 DOI: 10.1097/acm.0000000000004949] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The learning health care system is an aspirational operational model for improving health care by learning from the care being delivered. The model, which has been endorsed by the National Academy of Medicine, aligns naturally with academic health systems, which have a mission to improve care for their communities through research and education. In this scholarly perspective, the authors define the learning health care system concept and its historical relationship to academic health systems; explore opportunities for and barriers to realizing the learning health care system; and propose actions to achieve the learning health care system at the local, regional, and national levels. The authors argue that the learning health care system model is essential to academic medicine's evolution and to achieving the foundational societal mission of academic health systems to advance health through research and education.
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Affiliation(s)
- Harold R Collard
- H.R. Collard is professor of medicine and health policy, Department of Medicine, director, Clinical and Translational Science Institute, and associate vice chancellor, Clinical Research, University of California, San Francisco, San Francisco, California; ORCID: https://orcid.org/0000-0002-8384-9506
| | - Kevin Grumbach
- K. Grumbach is professor and chair, Department of Family and Community Medicine, director, Community Engagement Program, Clinical and Translational Science Institute, and senior medical director, Office of Population Health, University of California, San Francisco, San Francisco, California; ORCID: https://orcid.org/0000-0002-7809-214X
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McEvoy MD, Dear ML, Buie R, Edwards DA, Barrett TW, Allen B, Robertson AC, Fowler LC, Hennessy C, Miller BM, Garvey KV, Bland RP, Fleming GM, Moore D, Rice TW, Bernard GR, Lindsell CJ. Effect of Smartphone App-Based Education on Clinician Prescribing Habits in a Learning Health Care System: A Randomized Cluster Crossover Trial. JAMA Netw Open 2022; 5:e2223099. [PMID: 35881398 PMCID: PMC9327570 DOI: 10.1001/jamanetworkopen.2022.23099] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
IMPORTANCE Effective methods for engaging clinicians in continuing education for learning-based practice improvement remain unknown. OBJECTIVE To determine whether a smartphone-based app using spaced education with retrieval practice is an effective method to increase evidence-based practice. DESIGN, SETTING, AND PARTICIPANTS A prospective, unblinded, single-center, crossover randomized clinical trial was conducted at a single academic medical center from January 6 to April 24, 2020. Vanderbilt University Medical Center clinicians prescribing intravenous fluids were invited to participate in this study. INTERVENTIONS All clinicians received two 4-week education modules: 1 on prescribing intravenous fluids and 1 on prescribing opioid and nonopioid medications (counterbalancing measure), over a 12-week period. The order of delivery was randomized 1:1 such that 1 group received the fluid management module first, followed by the pain management module after a 4-week break, and the other group received the pain management module first, followed by the fluid management module after a 4-week break. MAIN OUTCOMES AND MEASURES The primary outcome was evidence-based clinician prescribing behavior concerning intravenous fluids in the inpatient setting and pain medication prescribing on discharge from the hospital. RESULTS A total of 354 participants were enrolled and randomized, with 177 in group 1 (fluid then pain management education) and 177 in group 2 (pain management then fluid education). During the overall study period, 16 868 questions were sent to 349 learners, with 11 783 (70.0%) being opened: 10 885 (92.4%) of those opened were answered and 7175 (65.9%) of those answered were answered correctly. The differences between groups changed significantly over time, indicated by the significant interaction between educational intervention and time (P = .002). Briefly, at baseline evidence-concordant IV fluid ordered 7.2% less frequently in group 1 than group 2 (95% CI, -19.2% to 4.9%). This was reversed after training at 4% higher (95% CI, -8.2% to 16.0%) in group 1 than group 2, a more than doubling in the odds of evidence-concordant ordering (OR, 2.56, 95% CI, 0.80-8.21). Postintervention, all gains had been reversed with less frequent ordering in group 1 than group 2 (-9.5%, 95% CI, -21.6% to 2.7%). There was no measurable change in opioid prescribing behaviors at any time point. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, use of smartphone app learning modules resulted in statistically significant short-term improvement in some prescribing behaviors. However, this effect was not sustained over the long-term. Additional research is needed to understand how to sustain improvements in care delivery as a result of continuous professional development at the institutional level. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03771482.
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Affiliation(s)
- Matthew D. McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mary Lynn Dear
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Reagan Buie
- Episodes of Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David A. Edwards
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tyler W. Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brian Allen
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amy C. Robertson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Leslie C. Fowler
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cassandra Hennessy
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bonnie M. Miller
- Department of the Office of Health Sciences Education, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kim V. Garvey
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert P. Bland
- Department of HealthIT Architecture and Integration, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Geoffrey M. Fleming
- Department of Pediatrics, Vanderbilt Children’s Hospital, Nashville, Tennessee
| | - Don Moore
- Professor of Medical Education and Administration, Emeritus, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Todd W. Rice
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gordon R. Bernard
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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