A Complexity Framework for Project Management Strategies

We examine how project complexity influences the choice of a project management strategy and present a framework that facilitates managers in selecting a suitable project management strategy. We distinguish the complexity of project domains from two dimensions, the degree of structural complexity and the degree of dynamic complexity, resulting in four generic project types. Four generic project management strategies are identified that match these project types. This complexity framework for project management allows key players to determine a better project management strategy and related practices given its content, the internal context, and the external environment.

The effects of a computerized clinical decision aid on clinical decision-making in psychosis care

OBJECTIVE

Clinicians in mental healthcare have few objective tools to identify and analyze their patient's care needs. Clinical decision aids are tools that support this process. This study examines whether 1) clinicians working with a clinical decision aid (TREAT) discuss more of their patient's care needs compared to usual treatment, and 2) agree on more evidence-based treatment decisions.

METHODS

Clinicians participated in consultations (n = 166) with patients diagnosed with psychotic disorders from four Dutch mental healthcare institutions (research registration number 201700763). Primary outcomes were measured with the modified Clinical Decision-making in Routine Care questionnaire and combined with psychiatric, physical and social wellbeing related care needs. A multilevel analysis compared discussed care needs and evidence-based treatment decisions between treatment as usual (TAU) before, TAU after and the TREAT condition.

RESULTS

First, a significant increase in discussed care needs for TREAT compared to both TAU conditions (β = 20.2, SE = 5.2, p = 0.00 and β = 15.8, SE = 5.4, p = 0.01) was found. Next, a significant increase in evidence-based treatments decisions for care needs was observed for TREAT compared to both TAU conditions (β = 16.7, SE = 4.8, p = 0.00 and β = 16.0, SE = 5.1, p = 0.01).

CONCLUSION

TREAT improved the discussion about physical health issues and social wellbeing related topics. It also increased evidence-based treatment decisions for care needs which are sometimes overlooked and difficult to treat. Our findings suggest that TREAT makes sense of routine outcome monitoring data and improves guideline-informed care.

The effects of a computerized clinical decision aid on clinical decision-making and guideline implementation in psychosis care

Introduction

Clinicians in mental healthcare have few objective tools to identify and analyse their patient’s care needs. Clinical decision aids are tools that can support this process.

Objectives

This study examines whether 1) clinicians working with a clinical decision aid (TREAT) discuss more of their patient’s care needs compared to usual treatment, and 2) agree on more evidence-based treatment decisions.

Methods

Clinicians participated in consultations (n=166) with patients diagnosed with psychotic disorders from four Dutch mental healthcare institutions. Primary outcomes were measured with the modified Clinical Decision-making in Routine Care questionnaire and combined with psychiatric, physical and social wellbeing related care needs. A multilevel analysis compared discussed care needs and evidence-based treatment decisions between treatment as usual (TAU) before, TAU after and the TREAT-condition.

Results

First, a significant increase in discussed care needs for TREAT compared to both TAU conditions (b = 20.2, SE = 5.2, p = 0.00 and b = 15.8, SE = 5.4, p = 0.01) was found. Next, a significant increase in evidence-based treatments decisions for care needs was observed for TREAT compared to both TAU conditions (b = 16.7, SE = 4.8, p = 0.00 and b = 16.0, SE = 5.1, p = 0.01).

Conclusions

TREAT improved the discussion about physical health issues and social wellbeing related topics. It also increased evidence-based treatment decisions for care needs which are sometimes overlooked and difficult to treat. Our findings suggest that TREAT makes sense of ROM data and improves guideline-informed care.

Disclosure

No significant relationships.

Influence of artificial intelligence on the work design of emergency department clinicians a systematic literature review

Objective

This systematic literature review aims to demonstrate how Artificial Intelligence (AI) is currently used in emergency departments (ED) and how it alters the work design of ED clinicians. AI is still new and unknown to many healthcare professionals in emergency care, leading to unfamiliarity with its capabilities.

Method

Various criteria were used to establish the suitability of the articles to answer the research question. This study was based on 34 selected peer-reviewed papers on the use of Artificial Intelligence (AI) in the Emergency Department (ED), published in the last five years. Drawing on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, all articles were scanned, read full-text, and analyzed afterward.

Results

The majority of the AI applications consisted of AI-based tools to aid with clinical decisions and to relieve overcrowded EDs of their burden. AI support was mostly offered during triage, the moment that sets the patient trajectory. There is ample evidence that AI-based applications could improve the clinical decision-making process.

Conclusion

The use of AI in EDs is still in its nascent stages. Many studies focus on the question of whether AI has clinical utility, such as decision support, improving resource allocation, reducing diagnostic errors, and promoting proactivity. Some studies suggest that AI-based tools essentially have the ability to outperform human skills. However, it is evident from the literature that current technology does not have the aims or power to do so. Nevertheless, AI-based tools can impact clinician work design in the ED by providing support with clinical decisions, which could ultimately help alleviate a portion of the increasing clinical burden.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08070-7.

A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log₁₀ increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence.

Medical Specialists' Perspectives on the Influence of Electronic Medical Record Use on the Quality of Hospital Care: Semistructured Interview Study

Background

Numerous publications show that electronic medical records (EMRs) may make an important contribution to increasing the quality of care. There are indications that particularly the medical specialist plays an important role in the use of EMRs in hospitals.

Objective

The aim of this study was to examine how, and by which aspects, the relationship between EMR use and the quality of care in hospitals is influenced according to medical specialists.

Methods

To answer this question, a qualitative study was conducted in the period of August-October 2018. Semistructured interviews of around 90 min were conducted with 11 medical specialists from 11 different Dutch hospitals. For analysis of the answers, we used a previously published taxonomy of factors that can influence the use of EMRs.

Results

The professional experience of the participating medical specialists varied between 5 and 27 years. Using the previously published taxonomy, these medical specialists considered technical barriers the most significant for EMR use. The suboptimal change processes surrounding implementation were also perceived as a major barrier. A final major problem is related to the categories “social” (their relationships with the patients and fellow care providers), “psychological” (based on their personal issues, knowledge, and perceptions), and “time” (the time required to select, implement, and learn how to use EMR systems and subsequently enter data into the system). However, the medical specialists also identified potential technical facilitators, particularly in the assured availability of information to all health care professionals involved in the care of a patient. They see promise in using EMRs for medical decision support to improve the quality of care but consider these possibilities currently lacking.

Conclusions

The 11 medical specialists shared positive experiences with EMR use when comparing it to formerly used paper records. The fact that involved health care professionals can access patient data at any time they need is considered important. However, in practice, potential quality improvement lags as long as decision support cannot be applied because of the lack of a fully coded patient record.

Persisting workarounds in Electronic Health Record System use: types, risks and benefits

Background

Electronic Health Records (EHRs) are now widely used to create a single, shared, and reliable source of patient data throughout healthcare organizations. However, health professionals continue to experience mismatches between their working practices and what the EHR allows or directs them to do. Health professionals adopt working practices other than those imposed by the EHR to overcome such mismatches, known as workarounds. Our study aims to inductively develop a typology of enduring EHR workarounds and explore their consequences by answering the question: What types of EHR workarounds persist, and what are the user-perceived consequences?

Methods

This single case study was conducted within the Internal Medicine department of a Dutch hospital that had implemented an organization-wide, commercial EHR system over two years ago. Data were collected through observations of six EHR users (see Additional file 1, observation scheme) and 17 semi-structured interviews with physicians, nurses, administrators, and EHR support staff members. Documents were analysed to contextualize these data (see Additional file 2, interview protocol).

Results

Through a qualitative analysis, 11 workarounds were identified, predominantly performed by physicians. These workarounds are categorized into three types either performed while working with the system (in-system workflow sequence workarounds and in-system data entry workarounds) or bypassing the system (out-system workarounds). While these workarounds seem to offer short-term benefits for the performer, they often create threats for the user, the patient, the overall healthcare organization, and the system.

Conclusion

This study increases our understanding of the enduring phenomenon of working around Electronic Health Records by presenting a typology of those workarounds that persist after adoption and by reflecting on the user-perceived risks and benefits. The typology helps EHR users and their managers to identify enduring types of workarounds and differentiate between the harmful and less harmful ones. This distinction can inform their decisions to discourage or obviate the need for certain workarounds, while legitimating others.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01548-0.

Qualitative analysis of clinicians' perspectives on the use of a computerized decision aid in the treatment of psychotic disorders

Background

Clinical decision aids are used in various medical fields to support patients and clinicians when making healthcare decisions. Few attempts have been made to implement such tools in psychiatry. We developed Treatment E-Assist (TREAT); a routine outcome monitoring based computerized clinical decision aid, which generates personalized treatment recommendations in the care of people with psychotic disorders. The aim of this study is to investigate how TREAT is used and evaluated by clinicians and how this tool can be improved.

Methods

Clinicians working with TREAT during a clinical trial were asked to participate in semi-structured interviews. The Unified Theory of Acceptance and Use of Technology (UTAUT) was used as a sensitizing theory to structure a part of the interview questions. The transcripts were analyzed using inductive thematic analysis to uncover the main themes.

Results

Thirteen clinicians (mean age: 49) of which eight psychiatrists and five nurse practitioners, participated in this study. Eight clinicians experienced TREAT as beneficial, whereas five experienced no additional benefits. Thematic analysis revealed five themes surrounding usage and evaluation of TREAT, views on TREAT’s graphic representation of routine outcome monitoring results, guideline based treatment recommendations, contextual factors, effects on patients and effects on shared decision-making. Performance and effort expectancy were perceived as high by clinicians. The facilitating conditions were optimal and perceived social influence was low.

Conclusion

This article presents a qualitative evaluation by clinicians of a computerized clinical decision aid in psychosis care. TREAT was viewed by most clinicians as beneficial during their consultations. The graphic representation of routine outcome monitoring results was well-appreciated and provided input to discuss treatment planning with patients. The treatment recommendations did not change most treatment decisions but supported clinical reasoning. However, some clinicians were unconvinced about TREAT’s benefits. The delivery, applicability and the availability of resources require improvement to increase TREAT’s efficacy. Not all patients responded well to TREAT but the observed facilitation of shared decision-making is promising. All four predictors of the Unified Theory of Acceptance and Use of Technology were positively evaluated by the majority of clinicians.

The influence of electronic health record use on collaboration among medical specialties

Background

One of the main objectives of Electronic Health Records (EHRs) is to enhance collaboration among healthcare professionals. However, our knowledge of how EHRs actually affect collaborative practices is limited. This study examines how an EHR facilitates and constrains collaboration in five outpatient clinics.

Methods

We conducted an embedded case study at five outpatient clinics of a Dutch hospital that had implemented an organization-wide EHR. Data were collected through interviews with representatives of medical specialties, administration, nursing, and management. Documents were analyzed to contextualize these data. We examined the following collaborative affordances of EHRs: (1) portability, (2) co-located access, (3) shared overviews, (4) mutual awareness, (5) messaging, and (6) orchestrating.

Results

Our findings demonstrate how an EHR will both facilitate and constrain collaboration among specialties and disciplines. Affordances that were inscribed in the system for collaboration purposes were not fully actualized in the hospital because:

(a) The EHR helps health professionals coordinate patient care on an informed basis at any time and in any place but only allows asynchronous patient record use.

(b) The comprehensive patient file affords joint clinical decision-making based on shared data, but specialty- and discipline-specific user-interfaces constrain mutual understanding of that data. Moreover, not all relevant information can be easily shared across specialties and outside the hospital.

(c) The reduced necessity for face-to-face communication saves time but is experienced as hindering collective responsibility for a smooth workflow.

(d) The EHR affords registration at the source and registration of activities through orders, but the heightened administrative burden for physicians and the strict authorization rules on inputting data constrain the flexible, multidisciplinary collaboration.

(e) While the EHR affords a complete overview, information overload occurs due to the parallel generation of individually owned notes and the high frequency of asynchronous communication through messages of varying clinical priority.

Conclusions

For the optimal actualization of EHRs’ collaborative affordances in hospitals, coordinated use of these affordances by health professionals is a prerequisite. Such coordinated use requires organizational, technical, and behavioral adaptations. Suggestions for hospital-wide policies to enhance trust in both the EHR and in its coordinated use for effective collaboration are offered.

High Treatment Uptake in Human Immunodeficiency Virus/Hepatitis C Virus-Coinfected Patients After Unrestricted Access to Direct-Acting Antivirals in the Netherlands

Background

The Netherlands has provided unrestricted access to direct-acting antivirals (DAAs) since November 2015. We analyzed the nationwide hepatitis C virus (HCV) treatment uptake among patients coinfected with human immunodeficiency virus (HIV) and HCV.

Methods

Data were obtained from the ATHENA HIV observational cohort in which >98% of HIV-infected patients ever registered since 1998 are included. Patients were included if they ever had 1 positive HCV RNA result, did not have spontaneous clearance, and were known to still be in care. Treatment uptake and outcome were assessed. When patients were treated more than once, data were included from only the most recent treatment episode. Data were updated until February 2017. In addition, each treatment center was queried in April 2017 for a data update on DAA treatment and achieved sustained virological response.

Results

Of 23574 HIV-infected patients ever linked to care, 1471 HCV-coinfected patients (69% men who have sex with men, 15% persons who [formerly] injected drugs, and 15% with another HIV transmission route) fulfilled the inclusion criteria. Of these, 87% (1284 of 1471) had ever initiated HCV treatment between 2000 and 2017, 76% (1124 of 1471) had their HCV infection cured; DAA treatment results were pending in 6% (92 of 1471). Among men who have sex with men, 83% (844 of 1022) had their HCV infection cured, and DAA treatment results were pending in 6% (66 of 1022). Overall, 187 patients had never initiated treatment, DAAs had failed in 14, and a pegylated interferon-alfa-based regimen had failed in 54.

Conclusions

Fifteen months after unrestricted DAA availability the majority of HIV/HCV-coinfected patients in the Netherlands have their HCV infection cured (76%) or are awaiting DAA treatment results (6%). This rapid treatment scale-up may contribute to future HCV elimination among these patients.

A STAT4 variant increases liver fibrosis risk in Caucasian patients with chronic hepatitis B

BACKGROUND

Host genetic modifiers of the natural history of chronic hepatitis B (CHB) remain poorly understood. Recently, a genome-wide association study (GWAS)-identified polymorphism in the STAT4 gene that contributes to the risk for hepatocellular carcinoma (HCC) was shown to be associated with the full spectrum of hepatitis B virus (HBV) outcomes in Asian patients. However, the functional mechanisms for this effect are unknown and the role of the variant in modulating HBV disease in Caucasians has not been investigated.

AIMS

To determine whether STAT4 genetic variation is associated with liver injury in Caucasian patients with CHB and to investigate potential mechanisms mediating this effect.

METHODS

STAT4 rs7574865 was genotyped in 1085 subjects (830 with CHB and 255 healthy controls). STAT4 expression in liver, PBMCs and NK cells, STAT4 phosphorylation and secretion of interferon-gamma (IFN-γ) according to STAT4 genetic variation was examined.

RESULTS

STAT4 rs7574865 genotype was independently associated with hepatic inflammation (OR: 1.42, 95% CI: 1.07-2.06, P = 0.02) and advanced fibrosis (OR: 1.83, 95% CI: 1.19-2.83, P = 0.006). The minor allele frequency of rs7574865 was significantly lower than that in healthy controls. rs7574865 GG risk carriers expressed lower levels of STAT4 in liver, PBMCs and in NK cells, while NK cells from patients with the risk genotype had impaired STAT4 phosphorylation following stimulation with IL-12/IL-18 and a reduction in secretion of IFN-γ.

CONCLUSION

Genetic susceptibility to HBV persistence, hepatic inflammation and fibrosis in Caucasians associates with STAT4 rs7574865 variant. Downstream effects on NK cell function through STAT4 phosphorylation-dependent IFN-γ production likely contribute to these effects.

The development and evaluation of a computerized decision aid for the treatment of psychotic disorders

BACKGROUND

Routinely monitoring of symptoms and medical needs can improve the diagnostics and treatment of medical problems, including psychiatric. However, several studies show that few clinicians use Routine Outcome Monitoring (ROM) in their daily work. We describe the development and first evaluation of a ROM based computerized clinical decision aid, Treatment-E-Assist (TREAT) for the treatment of psychotic disorders. The goal is to generate personalized treatment recommendations, based on international guidelines combined with outcomes of mental and physical health acquired through ROM. We present a pilot study aimed to assess the feasibility of this computerized clinical decision aid in daily clinical practice by evaluating clinicians' experiences with the system.

METHODS

Clinical decision algorithms were developed based on international schizophrenia treatment guidelines and the input of multidisciplinary expert panels from multiple psychiatric institutes. Yearly obtained diagnostic (ROM) information of patients was presented to treating clinicians combined with treatment suggestions generated by the algorithms of TREAT. In this pilot study 6 clinicians and 16 patients of Lentis Psychiatric Institute used the application. Clinicians were interviewed and asked to fill out self-report questionnaires evaluating their opinions about ROM and the effectiveness of TREAT.

RESULTS

Six clinicians and 16 patients with psychotic disorders participated in the pilot study. The clinicians were psychiatrists, physicians and nurse-practitioners which all worked at least 8 years in mental health care of which at least 3 years treating patients with psychotic illnesses. All Clinicians found TREAT easy to use and would like to continue using the application. They reported that TREAT offered support in using diagnostic ROM information when drafting the treatment plans, by creating more awareness of current treatment options.

CONCLUSION

This article presents a pilot study on the implementation of a computerized clinical decision aid linking routine outcome monitoring to clinical guidelines in order to generate personalized treatment advice. TREAT was found to be feasible for daily clinical practice and effective based on this first evaluation by clinicians. However, adjustments have to be made to the system and algorithms of the application. The ultimate goal is to provide appropriate evidence based care for patients with severe mental illnesses.

Prediction of long-term clinical outcome in a diverse chronic hepatitis B population: Role of the PAGE-B score

An abundance of noninvasive scores have been associated with fibrosis and hepatocellular carcinoma (HCC) development. We aimed to compare the prognostic ability of these scores in relation to liver histology in chronic hepatitis B (CHB) patients. Liver biopsies from treatment-naïve CHB patients at one tertiary care centre were scored by a single hepato-pathologist. Laboratory values at liver biopsy were used to calculate the PAGE-B, REACH-B, GAG-HCC, CU-HCC and FIB-4 scores. Any clinical event was defined as HCC development, liver failure, transplantation and mortality. HCC and mortality data were obtained from national database registries. Of 557 patients, 40 developed a clinical event within a median follow-up of 10.1 (IQR 5.7-15.9) years. The PAGE-B score predicted any clinical event (C-statistic.86, 95% CI: 0.80-0.92), HCC development (C-statistic .91) and reduced transplant-free survival (C-statistic .83) with good accuracy, also when stratified by ethnicity, antiviral therapy after biopsy or advanced fibrosis. The C-statistics (95% CI) of the REACH-B, GAG-HCC, CU-HCC and FIB-4 scores for any event were .70 (0.59-0.81), .82 (0.75-0.89), .73 (0.63-0.84) and.79 (0.69-0.89), respectively. The PAGE-B event risk assessment improved modestly when combined with the Ishak fibrosis stage (C-statistic .87, 95% CI: 0.82-0.93). The PAGE-B score showed the best performance in assessing the likelihood of developing a clinical event among a diverse CHB population over 15 years of follow-up. Additional liver histological characteristics did not appear to provide a clinically significant improvement.

NK cells in self-limited HCV infection exhibit a more extensively differentiated, but not memory-like, repertoire

Natural killer (NK) cells have long been thought of as a purely innate immune cell population, but increasing reports have described developmental and functional qualities of NK cells that are commonly associated with cells of the adaptive immune system. Of these features, the ability of NK cells to acquire functional qualities associated with immunological memory and continuous differentiation resulting in the formation of specific NK cell repertoires has recently been highlighted in viral infection settings. By making use of a unique cohort of monitored, at-risk intravenous drug users in this study, we were able to dissect the phenotypic and functional parameters associated with NK cell differentiation and NK cell memory in patients 3 years after acute HCV infection and either the subsequent self-clearance or progression to chronicity. We observed increased expression of cytolytic mediators and markers CD56^bright and NKp46⁺ of NK cells in patients with chronic, but not self-limited HCV infection. Patients with a self-limited infection expressed higher levels of differentiation-associated markers CD57 and KIRs, and lower levels of NKG2A. A more extensively differentiated NK cell phenotype is associated with self-clearance in HCV patients, while the NK cells of chronic patients exhibited more naïve and effector NK cell phenotypic and functional characteristics. The identification of these distinct NK cell repertoires may shed light on the role NK cells play in determining the outcome of acute HCV infections, and the underlying immunological defects that lead to chronicity.

Differential expression of innate immune response genes in clinical phases of chronic hepatitis B infection

We investigated innate immune gene expression in clinical phases of chronic hepatitis B infection, including immune tolerant (IT), immune active (IA), inactive carrier (IC) and hepatitis B e antigen (HBeAg)-negative phases, as well as healthy controls. Expression levels of interferon types I, II and III, their receptor subunits, IRFs, TLRs and other IFN-induced genes in peripheral blood mononuclear cells were compared. Forty HBsAg-positive treatment-naïve subjects without co-infection with HIV, HCV or HDV were enrolled. To complement the viral load, the expression levels of 37 innate immune genes were measured by qPCR. The highest response of the innate immune system was observed in the IT and HBeAg-negative phases, and the IC phase had the lowest response; 31 of the 37 studied genes reached their maximum mRNA expression levels in the IT and HBeAg-negative phases, and the minimum expression levels of 23 genes were found in the IC phase. The highest mRNA expression levels of IFNs, IFN receptor subunits, IRFs and TLRs genes in all clinical phases were IFN-λ2 and 3, IFN-γR2, IRF7 and TLR7, and the lowest levels of mRNA expression were observed for IFN-α, IFN-λR1, IRF8 and TLR2. We conclude that innate immune response genes are expressed differentially among chronic HBV phases, and this difference may help to develop new precise and noninvasive methods to determine the progression of disease in chronic HBV patients.

Exploring the use of Routine Outcome Monitoring in the treatment of patients with a psychotic disorder

BACKGROUND

Routine Outcome Monitoring (ROM) has become part of the treatment process in mental health care. However, studies have indicated that few clinicians in psychiatry use the outcome of ROM in their daily work. The aim of this study was to explore the degree of ROM use in clinical practice as well as the explanatory factors of this use.

METHODS

In the Northern Netherlands, a ROM-protocol (ROM-Phamous) for patients with a psychotic disorder has been implemented. To establish the degree of ROM-Phamous use in clinical practice, the ROM results of patients (n=204) were compared to the treatment goals formulated in their treatment plans. To investigate factors that might influence ROM use, clinicians (n=32) were asked to fill out a questionnaire about ROM-Phamous.

RESULTS

Care domains that were problematic according to the ROM-Phamous results were mentioned in the treatment plan in 28% of cases on average (range 5-45%). The use of ROM-Phamous in the treatment process varies considerably among clinicians. Most of the clinicians find ROM-Phamous both useful and important for good clinical practice. In contrast, the perceived ease-of-use is low and most clinicians report insufficient time to use ROM-Phamous.

CONCLUSIONS

More frequent ROM use should be facilitated in clinicians. This could be achieved by improving the fit with clinical routines and the ease-of-use of ROM systems. It is important for all stakeholders to invest in integrating ROM in clinical practice. Eventually, this might improve the diagnostics and treatment of patients in mental health care.

Tension Awareness of Stakeholders in Large Technology Projects: A Duality Perspective

This article analyzes the tensions evolving from project management dilemmas and how they relate to stakeholders in large technology projects. The study addresses an organization-wide electronic health record implementation in a large hospital. It adopts a duality lens in exploring whether and how these tensions materialize through stakeholder voices. In contrast to traditional linear and unitarist thinking in project management, duality thinking may lead to project management practices that acknowledge, appreciate, and accommodate the tensions originating from dilemmas inherent in complex projects. We propose three stakeholder roles that can contribute to project managers’ tension awareness and inform duality management.

Social media use in healthcare: A systematic review of effects on patients and on their relationship with healthcare professionals

Background

Since the emergence of social media in 2004, a growing percentage of patients use this technology for health related reasons. To reflect on the alleged beneficial and potentially harmful effects of social media use by patients, the aim of this paper is to provide an overview of the extant literature on the effects of social media use for health related reasons on patients and their relationship with healthcare professionals.

Methods

We conducted a systematic literature review on empirical research regarding the effects of social media use by patients for health related reasons. The papers we included met the following selection criteria: (1) published in a peer-reviewed journal, (2) written in English, (3) full text available to the researcher, (4) contain primary empirical data, (5) the users of social media are patients, (6) the effects of patients using social media are clearly stated, (7) satisfy established quality criteria.

Results

Initially, a total of 1,743 articles were identified from which 22 were included in the study. From these articles six categories of patients’ use of social media were identified, namely: emotional, information, esteem, network support, social comparison and emotional expression. The types of use were found to lead to seven identified types of effects on patients, namely improved self-management and control, enhanced psychological well-being, and enhanced subjective well-being, diminished subjective well-being, addiction to social media, loss of privacy, and being targeted for promotion. Social media use by patients was found to affect the healthcare professional and patient relationship, by leading to more equal communication between the patient and healthcare professional, increased switching of doctors, harmonious relationships, and suboptimal interaction between the patient and healthcare professional.

Conclusions

Our review provides insights into the emerging utilization of social media in healthcare. In particular, it identifies types of use by patients as well as the effects of such use, which may differ between patients and doctors. Accordingly, our results framework and propositions can serve to guide future research, and they also have practical implications for healthcare providers and policy makers.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1691-0) contains supplementary material, which is available to authorized users.

Spontaneous and natural cytotoxicity receptor-mediated cytotoxicity are effector functions of distinct natural killer subsets in hepatitis C virus-infected chimpanzees

In humans, CD16 and CD56 are used to identify functionally distinct natural killer (NK) subsets. Due to ubiquitous CD56 expression, this marker cannot be used to distinguish between NK cell subsets in chimpanzees. Therefore, functional analysis of distinct NK subsets during hepatitis C virus (HCV) infection has never been performed in these animals. In the present study an alternative strategy was used to identify four distinct NK subsets on the basis of the expression of CD16 and CD94. The expression of activating and inhibiting surface receptors showed that these subsets resemble human NK subsets. CD107 expression was used to determine degranulation of the different subsets in naive and HCV-infected chimpanzees. In HCV-infected chimpanzees increased spontaneous cytotoxicity was observed in CD94(high/dim) CD16(pos) and CD94(low) CD16(pos) subsets. By contrast, increased natural cytotoxicity receptor (NCR)- mediated degranulation after NKp30 and NKp44 triggering was demonstrated in the CD94(dim) CD16(neg) subset. Our findings suggest that spontaneous and NCR-mediated cytotoxicity are effector functions of distinct NK subsets in HCV-infected chimpanzees.

Hepatitis B core-related antigen levels are associated with response to entecavir and peginterferon add-on therapy in hepatitis B e antigen-positive chronic hepatitis B patients

Hepatitis B core-related antigen (HBcrAg), a new serum marker, may be useful in monitoring chronic hepatitis B infection. HBcrAg was measured in 175 hepatitis B e antigen-positive patients treated with entecavir (ETV) with or without peginterferon (PEG-IFN) add-on therapy. Decline in HBcrAg was stronger in patients with vs. without combined response (ETV: -3.22 vs. -1.71 log U/mL, p <0.001; PEG-IFN add-on: -3.16 vs. -1.83 IU/mL, p <0.001) and in patients with vs. without hepatitis B surface antigen (HBsAg) response (ETV: -2.60 vs. -1.74 log U/mL, p <0.001; PEG-IFN add-on: -2.38 vs. -2.15 log U/mL, p = 0.31). HBcrAg was associated with combined response (adjusted odds ratio 0.3, 95% confidence interval 0.2-0.5, p <0.001), but was not superior to quantitative HBsAg (qHBsAg).

Risk Factors for Sexual Transmission of Hepatitis C Virus Among Human Immunodeficiency Virus-Infected Men Who Have Sex With Men: A Case-Control Study

Background. Since 2000, incidence of sexually acquired hepatitis C virus (HCV)-infection has increased among human immunodeficiency virus (HIV)-infected men who have sex with men (MSM). To date, few case-control and cohort studies evaluating HCV transmission risk factors were conducted in this population, and most of these studies were initially designed to study HIV-related risk behavior and characteristics.

Methods. From 2009 onwards, HIV-infected MSM with acute HCV infection and controls (HIV-monoinfected MSM) were prospectively included in the MOSAIC (MSM Observational Study of Acute Infection with hepatitis C) study at 5 large HIV outpatient clinics in the Netherlands. Written questionnaires were administered, covering sociodemographics, bloodborne risk factors for HCV infection, sexual behavior, and drug use. Clinical data were acquired through linkage with databases from the Dutch HIV Monitoring Foundation. For this study, determinants of HCV acquisition collected at the inclusion visit were analyzed using logistic regression.

Results. Two hundred thirteen HIV-infected MSM (82 MSM with acute HCV infection and 131 MSM without) were included with a median age of 45.7 years (interquartile range [IQR], 41.0–52.2). Receptive unprotected anal intercourse (adjusted odds ratio [aOR], 5.01; 95% confidence interval [CI], 1.63–15.4), sharing sex toys (aOR, 3.62; 95% CI, 1.04–12.5), unprotected fisting (aOR, 2.57; 95% CI, 1.02–6.44), injecting drugs (aOR, 15.62; 95% CI, 1.27–192.6), sharing straws when snorting drugs (aOR, 3.40; 95% CI, 1.39–8.32), lower CD4 cell count (aOR, 1.75 per cubic root; 95% CI, 1.19–2.58), and recent diagnosis of ulcerative sexually transmitted infection (aOR, 4.82; 95% CI, 1.60–14.53) had significant effects on HCV acquisition.

Conclusions. In this study, both sexual behavior and biological factors appear to independently increase the risk of HCV acquisition among HIV-infected MSM.

Follicular T helper cells and humoral reactivity in kidney transplant patients

Memory B cells play a pivotal role in alloreactivity in kidney transplantation. Follicular T helper (Tfh) cells play an important role in the differentiation of B cells into immunoglobulin-producing plasmablasts [through interleukin (IL)-21]. It is unclear to what extent this T cell subset regulates humoral alloreactivity in kidney transplant patients, therefore we investigated the absolute numbers and function of peripheral Tfh cells (CD4(POS) CXCR5(POS) T cells) in patients before and after transplantation. In addition, we studied their relationship with the presence of donor-specific anti-human leucocyte antigen (HLA) antibodies (DSA), and the presence of Tfh cells in rejection biopsies. After transplantation peripheral Tfh cell numbers remained stable, while their IL-21-producing capacity decreased under immunosuppression. When isolated after transplantation, peripheral Tfh cells still had the capacity to induce B cell differentiation and immunoglobulin production, which could be inhibited by an IL-21-receptor-antagonist. After transplantation the quantity of Tfh cells was the highest in patients with pre-existent DSA. In kidney biopsies taken during rejection, Tfh cells co-localized with B cells and immunoglobulins in follicular-like structures. Our data on Tfh cells in kidney transplantation demonstrate that Tfh cells may mediate humoral alloreactivity, which is also seen in the immunosuppressed milieu.

Polymorphisms of HLA-DP are associated with response to peginterferon in Caucasian patients with chronic hepatitis B

BACKGROUND

Polymorphisms of the HLA-DP gene are associated with the natural clearance of the hepatitis B virus in Asian patients.

AIM

To investigate the association of HLA-DP polymorphisms with response to peginterferon (PEG-IFN) in Caucasian chronic hepatitis B (CHB) patients.

METHODS

We studied 262 Caucasian chronic hepatitis B patients infected with HBV genotype A or D, treated with PEG-IFN for 1 year in two randomised controlled trials (HBV 99-01 and PARC study). Response was defined as an HBV DNA <2000 IU/mL at 6 months post-treatment. Variations at HLA-DPA1 and HLA-DPB1 were genotyped.

RESULTS

Of the 262 patients, 58% was HBeAg-positive and HBV genotype A and D was observed in 32% and 68%, respectively. At 6 months post-treatment, 57 (22%) patients had achieved an HBV DNA <2000 IU/mL. HLA-DPB1 was independently associated with virological response [adjusted odds ratio (OR) 1.8, 95% confidence interval (CI):1.1-3.0, P = 0.025], and with an undetectable HBV DNA (adjusted OR 2.4 95% CI: 1.2-4.7, P = 0.015) when adjusted for HBeAg status and other known response modifiers. In HBeAg-positive patients, combined HBeAg seroconversion with HBV DNA <2000 IU/mL was increasingly observed with each addition of an HLA-DPB1 G-allele (adjusted OR 2.7, 95% CI: 1.2-5.9, P = 0.012). Furthermore, HLA-DPA1 and HLA-DPB1 haplotype block GG showed comparable results for virological and combined response.

CONCLUSION

In this large cohort of Caucasian chronic hepatitis B patients infected with HBV genotypes A or D, polymorphisms of HLA-DP are independently associated with both virological and serological response to PEG-IFN therapy at 6 months post-treatment.

Implementing electronic health records in hospitals: a systematic literature review

BACKGROUND

The literature on implementing Electronic Health Records (EHR) in hospitals is very diverse. The objective of this study is to create an overview of the existing literature on EHR implementation in hospitals and to identify generally applicable findings and lessons for implementers.

METHODS

A systematic literature review of empirical research on EHR implementation was conducted. Databases used included Web of Knowledge, EBSCO, and Cochrane Library. Relevant references in the selected articles were also analyzed. Search terms included Electronic Health Record (and synonyms), implementation, and hospital (and synonyms). Articles had to meet the following requirements: (1) written in English, (2) full text available online, (3) based on primary empirical data, (4) focused on hospital-wide EHR implementation, and (5) satisfying established quality criteria.

RESULTS

Of the 364 initially identified articles, this study analyzes the 21 articles that met the requirements. From these articles, 19 interventions were identified that are generally applicable and these were placed in a framework consisting of the following three interacting dimensions: (1) EHR context, (2) EHR content, and (3) EHR implementation process.

CONCLUSIONS

Although EHR systems are anticipated as having positive effects on the performance of hospitals, their implementation is a complex undertaking. This systematic review reveals reasons for this complexity and presents a framework of 19 interventions that can help overcome typical problems in EHR implementation. This framework can function as a reference for implementers in developing effective EHR implementation strategies for hospitals.

Precore and core promoter mutants are associated with higher HBeAg seroconversion but low disease remission rates in HBV patients treated with nucleos(t)ide analogues

HBeAg seroconversion in HBV patients is considered an important event. We determined precore (PC) and base core promoter (BCP) mutations in 137 HBeAg-positive nucleos(t)ide analogues (NA) treated patients by INNO-LiPA HBV PreCore assay (Innogenetics). The majority of patients with nongenotype A had PC/BCP mutants present at baseline (P = 0.02). During 29 months of therapy, 45 patients achieved HBeAg seroconversion. Probability of HBeAg seroconversion was higher in patients with PC and/or BCP mutants (P = 0.01). After HBeAg seroconversion, patients with BCP mutants had more HBeAg relapse (P = 0.07), and PC mutants less often achieved HBV DNA < 2000 IU/mL (P = 0.07).

Sustained virologic response after therapy with the HCV protease inhibitor narlaprevir in combination with peginterferon and ribavirin is durable through long-term follow-up

Achievement of a sustained virologic response (SVR) after peginterferon (PEG-IFN) and ribavirin (RBV) treatment is considered to be a marker for the cure of chronic hepatitis C virus (HCV) infection. Long-term follow-up of patients with SVR after treatment with a direct acting antiviral has not yet been described. We used a randomized placebo-controlled, double-blind, two-period phase 1b trial that was conducted in 40 HCV genotype 1 (treatment-naïve and treatment-experienced)-infected patients. Nineteen patients achieved SVR after treatment with the HCV protease inhibitor narlaprevir followed by PEG-IFN/RBV. In these patients, HCV-RNA tests were scheduled at 3, 6, 12 and 24 months after end of treatment. Patients were followed for a median of 27 months (range 15-32) after end of treatment with a median number of follow-up visits of 4 (range 3-8). All patients remained HCV-RNA negative over time. SVR achieved following narlaprevir and PEG-IFN/RBV-therapy was durable up to 32 months after the end of treatment.

Sensitive detection of hepatocellular injury in chronic hepatitis C patients with circulating hepatocyte-derived microRNA-122

As chronic hepatitis C patients with progressive disease can present themselves with normal ALT levels, more sensitive biomarkers are needed. MicroRNAs are newly discovered small noncoding RNAs that are stable and detectable in the circulation. We aimed to investigate the association between hepatocyte-derived microRNAs in serum and liver injury in patients with chronic hepatitis C. The hepatocyte-derived miR-122 and miR-192 were analysed in sera of 102 chronic HCV-infected patients and 24 healthy controls. Serum levels of miR-122 and miR-192 correlated strongly with ALT (R = 0.67 and R = 0.65, respectively, P < 0.001 for both). Median levels of miR-122 and miR-192 in HCV-infected patients were 23 times and 8 times higher as in healthy controls (P < 0.001 for both). Even within the HCV-infected patients with a normal ALT (n = 38), the levels of miR-122 and miR-192 were 12 times and 4 times higher compared with healthy controls (P < 0.001 for both). Multivariate logistic regression analyses showed that only miR-122 was a significant predictor of the presence of chronic HCV infection (P = 0.026). Importantly, miR-122 was also superior in discriminating chronic HCV-infected patients with a normal ALT from healthy controls compared with the ALT level (AUC = 0.97 vs AUC = 0.78, P = 0.007). In conclusion, our study confirmed that liver injury is associated with high levels of hepatocyte-derived microRNAs in circulation and demonstrated that in particular miR-122 is a sensitive marker to distinguish chronic hepatitis C patients from healthy controls. More sensitive blood markers would benefit especially those patients with minor levels of hepatocellular injury, who are not identified by current screening with ALT testing.

Implementation factors and their effect on e-Health service adoption in rural communities: a systematic literature review

Background

An ageing population is seen as a threat to the quality of life and health in rural communities, and it is often assumed that e-Health services can address this issue. As successful e-Health implementation in organizations has proven difficult, this systematic literature review considers whether this is so for rural communities. This review identifies the critical implementation factors and, following the change model of Pettigrew and Whipp, classifies them in terms of “context”, “process”, and “content”. Through this lens, we analyze the empirical findings found in the literature to address the question: How do context, process, and content factors of e-Health implementation influence its adoption in rural communities?

Methods

We conducted a systematic literature review. This review included papers that met six inclusion and exclusion criteria and had sufficient methodological quality. Findings were categorized in a classification matrix to identify promoting and restraining implementation factors and to explore whether any interactions between context, process, and content affect adoption.

Results

Of the 5,896 abstracts initially identified, only 51 papers met all our criteria and were included in the review. We distinguished five different perspectives on rural e-Health implementation in these papers. Further, we list the context, process, and content implementation factors found to either promote or restrain rural e-Health adoption. Many implementation factors appear repeatedly, but there are also some contradictory results. Based on a further analysis of the papers’ findings, we argue that interaction effects between context, process, and content elements of change may explain these contradictory results. More specifically, three themes that appear crucial in e-Health implementation in rural communities surfaced: the dual effects of geographical isolation, the targeting of underprivileged groups, and the changes in ownership required for sustainable e-Health adoption.

Conclusions

Rural e-Health implementation is an emerging, rapidly developing, field. Too often, e-Health adoption fails due to underestimating implementation factors and their interactions. We argue that rural e-Health implementation only leads to sustainable adoption (i.e. it “sticks”) when the implementation carefully considers and aligns the e-Health content (the “clicks”), the pre-existing structures in the context (the “bricks”), and the interventions in the implementation process (the “tricks”).

Hepatitis B virus suppresses the functional interaction between natural killer cells and plasmacytoid dendritic cells

Natural killer cells (NK) are one of the key players in the eradication and control of viral infections. Infections with the hepatitis B virus (HBV) may lead to persistence in a subgroup of patients, and impaired NK cell functions have been observed in these patients. Crosstalk with other immune cells has been shown to modulate the function of NK cells. We studied the functional crosstalk between NK cells and plasmacytoid dendritic cell (pDC) and its modulation by HBV. Healthy human peripheral blood-derived NK cells and pDC were purified and cocultured in the presence or absence of HepG2.2.15-derived HBV under various in vitro conditions. The functionality of NK cells was assessed by evaluation of activation markers, cytokine production and cytotoxicity of carboxyfluorescein succinimidyl ester-labelled K562 target cells by flow cytometry or immunoassays. Additionally, the crosstalk was examined using NK and pDC from patients with chronic HBV. The activation of NK cells in cocultures with pDC, as demonstrated by CD69, CD25 and HLA-DR, was not affected by the presence of HBV. Similarly, when cocultured with pDC, the cytotoxic potential of NK cells was not influenced by HBV. However, HBV significantly inhibited pDC-induced IFN-γ production by NK cells both in the presence and in the absence of CpG. As HBV did not affect cytokine-induced IFN-γ production by NK cells cultured alone, the suppressive effect of HBV on NK cell function was mediated via interference with pDC-NK cell interaction. In contrast to other viruses, HBV does not activate pDC-NK cell interaction but inhibits pDC-induced NK cell function. In parallel with NK cells of patients with chronic HBV, which show diminished cytokine production with normal cytotoxicity, HBV specifically suppressed pDC-induced IFN-γ production by NK cells without affecting their cytolytic ability. These data demonstrate that HBV modulates pDC-NK cell crosstalk, which may contribute to HBV persistence.

Randomised clinical trial: anti-viral activity of ANA773, an oral inducer of endogenous interferons acting via TLR7, in chronic HCV

BACKGROUND

The ANA773 is an oral prodrug of a small-molecule toll-like receptor (TLR)7 agonist. Preclinical and healthy volunteer clinical studies with ANA773 have demonstrated induction of endogenous interferon-α (IFN-α) of multiple subtypes, which supports the potential utility in the treatment of chronic hepatitis C virus (HCV) infection.

AIM

To examine safety, tolerability, pharmacodynamics, pharmacokinetics and anti-viral activity of ANA773.

METHODS

The ANA773 was investigated in a double-blind, placebo-controlled study in 34 patients chronically infected with HCV of any genotype. Patients were treatment-naïve or had relapsed following previous interferon-based treatment. This dose escalation study was composed of four dose groups (800, 1200, 1600 and 2000mg). In each group, six to eight patients received ANA773 and two received placebo. Patients were dosed with ANA773 every-other-day for either 28 days (800, 1200 or 1600mg) or 10days (2000mg).

RESULTS

Mild to moderate adverse events were reported, with an increase in frequency and intensity with increasing dose. No serious AEs were reported and there were no early discontinuations. There were dose-related increases in various markers of IFN-α response. The mean maximum change in serum HCV RNA level from baseline was -0.34, -0.29, -0.40, -0.97 and -1.26log(10) in the placebo, 800, 1200, 1600 and 2000mg cohorts, respectively. At the 2000mg dose, ANA773 significantly (P=0.037) reduced serum HCV RNA levels (range: 0.14 to -3.10log(10) ).

CONCLUSION

The ANA773 was generally well tolerated and resulted in a dose-related IFN-dependent response leading to a significant decrease in serum HCV RNA levels in the 2000mg dose group.

Early morbidity encountered in the dietary-related mouse model of Barrett's esophagus: a question of zinc?

Recently, a mouse model for Barrett's esophagus based on a zinc-deficient diet supplemented with deoxycholic bile acids has been published. The aim of this study was to attempt to reproduce these data and extend them by employing genetically modified mice and intraperitoneal iron supplementation. The study design encompassed six experimental groups (wild type, Apc-mutant and Smad4-mutant mice, with or without iron injections), with all animals fed with the zinc-deficient diet supplemented with deoxycholic bile acids. All treatments were started at 3-5 weeks of age (the majority [78%] at 5 weeks). Animals were scheduled for euthanasia at two distinct time points, namely at 3 and 6 months of age. All mice showed signs of considerable distress already 4 weeks after the start of the modified diets, and had to be euthanized before the first evaluation time point (mean age 9.3 weeks, range 5-15 weeks). No differences were observed between wild type and genetically modified mice, or between animals with or without iron supplementation. On histological examination, we could not detect any lesions (Barrett's esophagus-like or tumors) other than esophagitis. In the currently presented experimental settings, we were not able to reproduce the mouse model according to which Barrett's-like lesions could be detected in animals fed with the zinc-deficient diet supplemented with deoxycholic bile acids.

Risk Management Affecting IS/IT Project Success through Communicative Action

Project risk management is defined in the literature as being instrumental action based on rational problem solving. Research indicates limited positive effects of an exclusive focus of instrumental action on project success. This article proposes to extend this instrumental view through communicative action. This theoretical broadening was explored by interviewing project stakeholders about project success and risk management application. Analysis demonstrates stakeholders deliberately use risk management to convey messages to others, with the aim of influencing their behavior, synchronizing their perception, and making them aware of the context and their responsibilities. Stakeholders perceive these effects as contributing to project success.

Identifying and Managing Stakeholders in Enterprise Information System Projects

identify and manage stakeholders engaged in the project. This article argues that this activity should go beyond the traditional ideas about user participation and management involvement. Also suppliers, customers, government agencies, business partners and the general public can have a clear interest in the ways that the system will be designed and implemented. This article proposes to apply identification, analysis and intervention techniques from organization and management disciplines in the IS field to enhance the changes for the successfulness of enterprise information system implementations. Some of these techniques are combined in a coherent method that may help implementers of complex IS projects to identify and categorize stakeholders and to consider appropriate ways of involvement during the various stages of the project.

Iron deficiency is common in idiopathic pulmonary arterial hypertension

The aims of this study were to assess the prevalence of iron deficiency in idiopathic pulmonary arterial hypertension (IPAH) and investigate whether oral iron supplementation has effects in iron-deficient patients. Iron parameters were measure for all IPAH patients attending our centre (VU University Medical Center, Amsterdam, the Netherlands) between May 2009 and February 2010. Iron data were related to clinical parameters, including 6-min walking distance (6MWD), and haemodynamic parameters measured during right heart catheterisation. In a subset of iron-deficient patients, the uptake of iron from the bowel was studied after administering oral iron for 4 weeks. Iron deficiency was found in 30 (43%) out of 70 patients. 6MWD was reduced in iron-deficient patients compared with iron-sufficient patients (mean±sd 390±138 versus 460±143 m; p<0.05) irrespective of the existence of anaemia. In a subset of 18 patients that received oral iron, ferritin levels were significantly increased, although eight patients only slightly increased their iron storage. This study shows that iron deficiency is frequently present in IPAH and is associated with a lower exercise capacity. The small response to oral iron in 44% of the treated patients suggests impaired iron absorption in these patients.

Barriers to the acceptance of electronic medical records by physicians from systematic review to taxonomy and interventions

Background

The main objective of this research is to identify, categorize, and analyze barriers perceived by physicians to the adoption of Electronic Medical Records (EMRs) in order to provide implementers with beneficial intervention options.

Methods

A systematic literature review, based on research papers from 1998 to 2009, concerning barriers to the acceptance of EMRs by physicians was conducted. Four databases, "Science", "EBSCO", "PubMed" and "The Cochrane Library", were used in the literature search. Studies were included in the analysis if they reported on physicians' perceived barriers to implementing and using electronic medical records. Electronic medical records are defined as computerized medical information systems that collect, store and display patient information.

Results

The study includes twenty-two articles that have considered barriers to EMR as perceived by physicians. Eight main categories of barriers, including a total of 31 sub-categories, were identified. These eight categories are: A) Financial, B) Technical, C) Time, D) Psychological, E) Social, F) Legal, G) Organizational, and H) Change Process. All these categories are interrelated with each other. In particular, Categories G (Organizational) and H (Change Process) seem to be mediating factors on other barriers. By adopting a change management perspective, we develop some barrier-related interventions that could overcome the identified barriers.

Conclusions

Despite the positive effects of EMR usage in medical practices, the adoption rate of such systems is still low and meets resistance from physicians. This systematic review reveals that physicians may face a range of barriers when they approach EMR implementation. We conclude that the process of EMR implementation should be treated as a change project, and led by implementers or change managers, in medical practices. The quality of change management plays an important role in the success of EMR implementation. The barriers and suggested interventions highlighted in this study are intended to act as a reference for implementers of Electronic Medical Records. A careful diagnosis of the specific situation is required before relevant interventions can be determined.