1
|
Strechen I, Herasevich S, Barwise A, Garcia-Mendez J, Rovati L, Pickering B, Diedrich D, Herasevich V. Centralized Multipatient Dashboards' Impact on Intensive Care Unit Clinician Performance and Satisfaction: A Systematic Review. Appl Clin Inform 2024; 15:414-427. [PMID: 38574763 PMCID: PMC11136527 DOI: 10.1055/a-2299-7643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 04/03/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Intensive care unit (ICU) clinicians encounter frequent challenges with managing vast amounts of fragmented data while caring for multiple critically ill patients simultaneously. This may lead to increased provider cognitive load that may jeopardize patient safety. OBJECTIVES This systematic review assesses the impact of centralized multipatient dashboards on ICU clinician performance, perceptions regarding the use of these tools, and patient outcomes. METHODS A literature search was conducted on February 9, 2023, using the EBSCO CINAHL, Cochrane Central Register of Controlled Trials, Embase, IEEE Xplore, MEDLINE, Scopus, and Web of Science Core Collection databases. Eligible studies that included ICU clinicians as participants and tested the effect of dashboards designed for use by multiple users to manage multiple patients on user performance and/or satisfaction compared with the standard practice. We narratively synthesized eligible studies following the SWiM (Synthesis Without Meta-analysis) guidelines. Studies were grouped based on dashboard type and outcomes assessed. RESULTS The search yielded a total of 2,407 studies. Five studies met inclusion criteria and were included. Among these, three studies evaluated interactive displays in the ICU, one study assessed two dashboards in the pediatric ICU (PICU), and one study examined centralized monitor in the PICU. Most studies reported several positive outcomes, including reductions in data gathering time before rounds, a decrease in misrepresentations during multidisciplinary rounds, improved daily documentation compliance, faster decision-making, and user satisfaction. One study did not report any significant association. CONCLUSION The multipatient dashboards were associated with improved ICU clinician performance and were positively perceived in most of the included studies. The risk of bias was high, and the certainty of evidence was very low, due to inconsistencies, imprecision, indirectness in the outcome measure, and methodological limitations. Designing and evaluating multipatient tools using robust research methodologies is an important focus for future research.
Collapse
Affiliation(s)
- Inna Strechen
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care, Mayo Clinic, Rochester, Minnesota, United States
| | - Svetlana Herasevich
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care, Mayo Clinic, Rochester, Minnesota, United States
| | - Amelia Barwise
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Juan Garcia-Mendez
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care, Mayo Clinic, Rochester, Minnesota, United States
| | - Lucrezia Rovati
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, United States
- Department of Emergency Medicine, University of Milano-Bicocca, School of Medicine and Surgery, Milan, Italy
| | - Brian Pickering
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care, Mayo Clinic, Rochester, Minnesota, United States
| | - Daniel Diedrich
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care, Mayo Clinic, Rochester, Minnesota, United States
| | - Vitaly Herasevich
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care, Mayo Clinic, Rochester, Minnesota, United States
| |
Collapse
|
2
|
Vaa Stelling B, Halvorsen AJ, Dupras D, Kearns L, Kisielewski M, Martin SK, Uthlaut B, Leasure E. Management of the Electronic Health Record Inbox: Results From a National Survey of Internal Medicine Program Directors. J Grad Med Educ 2023; 15:711-717. [PMID: 38045943 PMCID: PMC10686644 DOI: 10.4300/jgme-d-23-00165.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/21/2023] [Accepted: 09/21/2023] [Indexed: 12/05/2023] Open
Abstract
Background Internal medicine (IM) resident physicians spend a considerable amount of time managing their inbox as part of their longitudinal continuity clinic experience. There are no standardized guidelines for how programs should train, monitor, or supervise residents in this type of patient care. Objective To understand how IM residency programs educate, monitor, and supervise resident electronic health record (EHR) inbox management as part of their longitudinal continuity clinic and determine whether patient safety events have occurred due to EHR inbox-related patient care decisions made by unsupervised resident physicians. Methods In August 2021, 439 program directors at accredited US IM residency programs who were members of the Association of Program Directors in Internal Medicine (APDIM) were asked 12 questions developed by the study authors and APDIM survey committee members regarding resident EHR inbox management as part of the annual APDIM survey. Results Two hundred and sixty-seven (61%) PDs responded. The majority (224 of 267, 84%) of programs provided guidelines for expected message response times; less than half (115, 43%) monitored timeliness metrics. Only half (135; 51%) of programs required faculty supervision of inbox messages for all residents; 28% (76) did not require supervision for any residents. Twenty-one percent of PDs (56) reported awareness of a patient safety event occurring due to an unsupervised resident inbox-related patient care decision. Conclusions Substantial variability exists in how IM residency programs train, monitor, supervise, and provide coverage for resident inbox work. Program directors are aware of patient safety events resulting from unsupervised resident inbox management.
Collapse
Affiliation(s)
- Brianna Vaa Stelling
- Brianna Vaa Stelling, MD, is Assistant Professor of Medicine, Internal Medicine Residency Program, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew J. Halvorsen
- Andrew J. Halvorsen, MS, is Assistant Professor of Medicine, Internal Medicine Residency Program, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Denise Dupras
- Denise Dupras, MD, PhD, is Associate Professor of Medicine, Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Lisa Kearns
- Lisa Kearns, MD, MS, is General Internist, Memorial Health, Columbus, Ohio, USA
| | - Michael Kisielewski
- Michael Kisielewski, MA, is Assistant Director of Surveys and Research, Alliance for Academic Internal Medicine, Alexandria, Virginia, USA
| | - Shannon K. Martin
- Shannon K. Martin, MD, MS, is Associate Professor of Medicine, Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Brian Uthlaut
- Brian Uthlaut, MD, is Associate Professor of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA; and
| | - Emily Leasure
- Emily Leasure, MD, is Assistant Professor of Medicine, Internal Medicine Residency Program, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
3
|
Puranik C, Slavik A, Pickett K, Dani A, Generalovich Z, Neveaux L, de Peralta T. Development of integrated electronic medical and dental record competencies and impact of training modalities. J Dent Educ 2023; 87:660-668. [PMID: 36718532 DOI: 10.1002/jdd.13175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 10/23/2022] [Accepted: 12/17/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The American Recovery and Reinvestment Act provided incentives for the adoption of electronic health records. The integrated electronic medical and dental records (iEMDRs) can minimize healthcare charting errors. The use of iEMDR by healthcare students requires training and competence. There are no defined student competencies to assess the effective and responsible use of iEMDR in dentistry. The goal of this study was to propose a student competency model and study the impact of training modalities on iEMDR competency. METHODS This retrospective observational cohort study evaluated de-identified assessment scores (AS) and performance scores (PS) in predoctoral dental student (PDS) and advanced standing predoctoral (ASP) student cohorts that received remote or in-person iEMDR training. The AS and PS evaluated the knowledge and application of iEMDR, respectively. A voluntary survey evaluated students' self-perceived preparedness for iEMDR use. Linear regressions were used to determine the association between training modality and scores. Mantel-Haenszel ordinal chi-square tested differences between groups and agreement by training type. Statistical significance was set at 0.05. RESULTS The sample size (N = 214) provided 95% power to detect differences between study groups. The knowledge of iEMDR (AS) was not impacted due to the training type (p = 0.90) in either student cohorts, whereas the application of knowledge (PS) was higher in ASP student cohort after remote training (p < 0.001) as compared to PDS student cohort. Higher proportion of students perceived preparedness after remote learning in comparison to in-person training (p < 0.001). DISCUSSION The iEMDR competency model was useful to test the effective and responsible use of iEMDR, and remote training improved students' self-perceived preparedness.
Collapse
Affiliation(s)
- Chaitanya Puranik
- Department of Pediatric Dentistry, Children's Hospital Colorado and School of Dental Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Amanda Slavik
- Doctor of Dental Surgery Candidate, School of Dental Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Kaci Pickett
- Center for Research Outcomes in Children's Surgery (ROCS), Children's Hospital Colorado, Aurora, Colorado, USA
| | - Aditee Dani
- Graduate Student in Analytics Program, University of Harrisburg, Harrisburg, Pennsylvania, USA
| | - Zora Generalovich
- Clinical Application Services, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Lindsay Neveaux
- Department of Pediatric Dentistry, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Tracy de Peralta
- Senior Associate Dean of Academic Affairs and Inovation, School of Dental Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| |
Collapse
|
4
|
Jin DP, Samuel S, Bowden K, Mohan V, Gold JA. Just-in-Time Electronic Health Record Retraining to Support Clinician Redeployment during the COVID-19 Surge. Appl Clin Inform 2022; 13:949-955. [PMID: 36037835 PMCID: PMC9534598 DOI: 10.1055/a-1933-1798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 08/26/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND In response to surges in demand for intensive care unit (ICU) care related to the COVID-19 pandemic, health care systems have had to increase hospital capacity. One institution redeployed certified registered nurse anesthetists (CRNAs) as ICU clinicians, which necessitated training in ICU-specific electronic health record (EHR) workflows prior to redeployment. Under time- and resource-constrained settings, clinical informatics (CI) fellows could effectively be lead instructors for such training. OBJECTIVE This study aimed to deploy CI fellows as lead EHR instructional trainers for clinician redeployment as part of an organization's response to disaster management. METHODS CI fellows led a multidisciplinary team alongside subject matter experts to develop and deploy a tailored EHR curriculum comprising in-person classes and online video modules, leveraging high-fidelity simulated patient cases. The participants completed surveys immediately after the in-person training session and after deployment. RESULTS Eighteen CRNAs participated, with 15 completing the postactivity survey (83%). All felt the training was useful and improved their EHR skills with a Net Promoter score of +87. Most (93%) respondents indicated the pace of the session was "just right," and 100% felt the clarity of instruction was "just right" or "extremely easy" to understand. Twelve participants (67%) completed the postdeployment survey. The training increased comfort in the ICU for all respondents, and 91% felt the training prepared them to work in the ICU with minimal guidance. All stated that the concepts learned would be useful in their anesthesia role. Fifty-eight percent viewed the online video library. CONCLUSION This case report demonstrates that CI fellows with dual domain expertise in their clinical specialty and informatics are uniquely poised to deliver clinician redeployment EHR training in response to operational crises. Such opportunities can achieve fellowship educational goals while conserving physician resources which can be a strategic option as organizations plan for disaster management.
Collapse
Affiliation(s)
- Da P. Jin
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, United States
- Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, Oregon, United States
| | - Sunil Samuel
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, United States
| | - Kristin Bowden
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, United States
| | - Vishnu Mohan
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, United States
| | - Jeffrey A. Gold
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, United States
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland, Oregon, United States
| |
Collapse
|
5
|
Lou SS, Lew D, Harford DR, Lu C, Evanoff BA, Duncan JG, Kannampallil T. Temporal Associations Between EHR-Derived Workload, Burnout, and Errors: a Prospective Cohort Study. J Gen Intern Med 2022; 37:2165-2172. [PMID: 35710654 PMCID: PMC9296727 DOI: 10.1007/s11606-022-07620-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 04/13/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The temporal progression and workload-related causal contributors to physician burnout are not well-understood. OBJECTIVE To characterize burnout's time course and evaluate the effect of time-varying workload on burnout and medical errors. DESIGN Six-month longitudinal cohort study with measurements of burnout, workload, and wrong-patient orders every 4 weeks. PARTICIPANTS Seventy-five intern physicians in internal medicine, pediatrics, and anesthesiology at a large academic medical center. MAIN MEASURES Burnout was measured using the Professional Fulfillment Index survey. Workload was collected from electronic health record (EHR) audit logs and summarized as follows: total time spent on the EHR, after-hours EHR time, patient load, inbox time, chart review time, note-writing time, and number of orders. Wrong-patient orders were assessed using retract-and-reorder events. KEY RESULTS Seventy-five of 104 interns enrolled (72.1%) in the study. A total of 337 surveys and 8,863,318 EHR-based actions were analyzed. Median burnout score across the cohort across all time points was 1.2 (IQR 0.7-1.7). Individual-level burnout was variable (median monthly change 0.3, IQR 0.1-0.6). In multivariable analysis, increased total EHR time (β=0.121 for an increase from 54.5 h per month (25th percentile) to 123.0 h per month (75th percentile), 95%CI=0.016-0.226), increased patient load (β=0.130 for an increase from 4.9 (25th percentile) to 7.1 (75th percentile) patients per day, 95%CI=0.053-0.207), and increased chart review time (β=0.096 for an increase from 0.39 (25th percentile) to 0.59 (75th percentile) hours per patient per day, 95%CI=0.015-0.177) were associated with an increased burnout score. After adjusting for the total number of ordering sessions, burnout was not statistically associated with an increased rate of wrong-patient orders (rate ratio=1.20, 95%CI=0.76-1.89). CONCLUSIONS Burnout and recovery were associated with recent clinical workload for a cohort of physician trainees, highlighting the elastic nature of burnout. Wellness interventions should focus on strategies to mitigate sustained elevations of work responsibilities.
Collapse
Affiliation(s)
- Sunny S Lou
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, USA
| | - Daphne Lew
- Division of Biostatistics, Washington University School of Medicine, St Louis, MO, USA
| | - Derek R Harford
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, USA
| | - Chenyang Lu
- Department of Computer Science, Washington University in St Louis, St Louis, MO, USA
| | - Bradley A Evanoff
- Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Jennifer G Duncan
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - Thomas Kannampallil
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, USA. .,Institute for Informatics, Washington University School of Medicine, St Louis, MO, USA.
| |
Collapse
|
6
|
Corby S, Ash JS, Whittaker K, Mohan V, Solberg N, Becton J, Bergstrom R, Orwoll B, Hoekstra C, Gold JA. Translating ethnographic data into knowledge, skills, and attitude statements for medical scribes: a modified Delphi approach. J Am Med Inform Assoc 2022; 29:1679-1687. [PMID: 35689649 DOI: 10.1093/jamia/ocac091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/13/2022] [Accepted: 06/02/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE While the use of medical scribes is rapidly increasing, there are not widely accepted standards for their training and duties. Because they use electronic health record systems to support providers, inadequately trained scribes can increase patient safety related risks. This paper describes the development of desired core knowledge, skills, and attitudes (KSAs) for scribes that provide the curricular framework for standardized scribe training. MATERIALS AND METHODS A research team used a sequential mixed qualitative methods approach. First, a rapid ethnographic study of scribe activities was performed at 5 varied health care organizations in the United States to gather qualitative data about knowledge, skills, and attitudes. The team's analysis generated preliminary KSA related themes, which were further refined during a consensus conference of subject-matter experts. This was followed by a modified Delphi study to finalize the KSA lists. RESULTS The team identified 90 descriptions of scribe-related KSAs and subsequently refined, categorized, and prioritized them for training development purposes. Three lists were ultimately defined as: (1) Hands-On Learning KSA list with 47 items amenable to simulation training, (2) Didactic KSA list consisting of 32 items appropriate for didactic lecture teaching, and (3) Prerequisite KSA list consisting of 11 items centered around items scribes should learn prior to being hired or soon after being hired. CONCLUSION We utilized a sequential mixed qualitative methodology to successfully develop lists of core medical scribe KSAs, which can be incorporated into scribe training programs.
Collapse
Affiliation(s)
- Sky Corby
- Department of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Joan S Ash
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Keaton Whittaker
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Vishnu Mohan
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Nicholas Solberg
- Department of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - James Becton
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Robby Bergstrom
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Benjamin Orwoll
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA.,Department of Pediatric Critical Care, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Christopher Hoekstra
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Jeffrey A Gold
- Department of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA.,Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| |
Collapse
|
7
|
Pilot Testing of Simulation in the Evaluation of a Novel, Rapidly Deployable Electronic Health Record for use in Disaster Intensive Care. Disaster Med Public Health Prep 2021; 17:e51. [PMID: 34674787 DOI: 10.1017/dmp.2021.302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The SARS-CoV-2 pandemic has highlighted the need for rapid creation and management of ICU field hospitals with effective remote monitoring which is dependent on the rapid deployment and integration of an Electronic Health Record (EHR). We describe the use of simulation to evaluate a rapidly scalable hub-and-spoke model for EHR deployment and monitoring using asynchronous training. METHODS We adapted existing commercial EHR products to serve as the point of entry from a simulated hospital and a separate system for tele-ICU support and monitoring of the interfaced data. To train our users we created a modular video-based curriculum to facilitate asynchronous training. Effectiveness of the curriculum was assessed through completion of common ICU documentation tasks in a high-fidelity simulation. Additional endpoints include assessment of EHR navigation, user satisfaction (Net Promoter), system usability (System Usability Scale-SUS), and cognitive load (NASA-TLX). RESULTS A total of 5 participants achieved a 100% task completion on all domains except ventilator data (91%). Systems demonstrated high degrees of satisfaction (Net Promoter = 65.2), acceptable usability (SUS = 66.5), and acceptable cognitive load (NASA-TLX = 41.5); with higher levels of cognitive load correlating with the number of screens employed. CONCLUSIONS Clinical usability of a comprehensive and rapidly deployable EHR was acceptable in an intensive care simulation which was preceded by < 1 hour of video education about the EHR. This model should be considered in plans for integrated clinical response with remote and accessory facilities.
Collapse
|
8
|
Mohan V, Garrison C, Gold J. Using A New Model of Electronic Health Record Training To Reduce Physician Burnout: A Plan For Action. JMIR Med Inform 2021; 9:e29374. [PMID: 34325400 PMCID: PMC8491113 DOI: 10.2196/29374] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 06/28/2021] [Accepted: 07/25/2021] [Indexed: 11/13/2022] Open
Abstract
UNSTRUCTURED Physician burnout has been growing in the US at an alarming rate, and healthcare organizations are beginning to invest significant resources in combating this phenomenon. While the causes for burnout are multifactorial, a key issue that affects physicians is that they spend a significant proportion of their time interacting with their electronic health record (EHR), primarily because of the need to sift through increasing amounts of patient data coupled with a significant documentation burden. This has led to physicians spending increasing amounts time with the EHR after hours trying to catch up on paperwork ("pajama time"), which is a factor linked to burnout. In this paper we propose an innovative model of EHR training utilizing high-fidelity EHR simulation designed to facilitate efficient optimization of EHR use by clinicians, and emphasize the importance of both lifelong learning and physician well-being.
Collapse
Affiliation(s)
- Vishnu Mohan
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, 3181 SW Sam Jackson Park RdMail Code BICC, Portland, US
| | - Cort Garrison
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, 3181 SW Sam Jackson Park RdMail Code BICC, Portland, US
| | - Jeffrey Gold
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland, US
| |
Collapse
|