Creativity in Health Communication to Promote Blood Lead Testing in Children

Low rates of blood lead level screening among young children persist as a public health issue in the United States, including in Texas where levels remain below the national average. This article describes a multiyear, multipartner initiative aimed at increasing screening rates through a creative, community-informed social media campaign. Interviews with parents, providers, and state health department staff revealed a common perception that lead poisoning was a relic of the past. Using these insights, the team developed humorous social media messaging comparing extinct animals to lead poisoning to capture attention and change attitudes about lead's current relevance. The "#GetLeadCheckedTexas" campaign ran on state health department channels during National Lead Poisoning Prevention Week in October 2020. Colorful graphics depicted extinct creatures like dinosaurs along with their babies, playing on childhood enthusiasm for such animals while evoking protective feelings in parents. Messaging highlighted lead's dangers for young children and encouraged viewers to discuss testing with providers. Website analytics showed the campaign drove substantial increases in page views for lead screening resources, particularly among providers. While originally designed with a parent audience in mind, the campaign seemed to resonate more with providers, likely due to timing during an awareness week and use of official health department channels. The initiative demonstrates the value of creative communications approaches employed in traditional advertising to raise awareness and promote public health priorities. Audience research, thoughtful use of humor, and designing human-focused messaging helped cut through information clutter and drive engagement with an important childhood health issue.

Social and Health Information Platform: Piloting a Standards-Based, Digital Platform Linking Social Determinants of Health Data into Clinical Workflows for Community-Wide Use

BACKGROUND

Social determinants of health (SDoH)a are increasingly recognized as a main contributor to clinical health outcomes, but the technologies and workflows within clinics make it difficult for health care providers to address SDoH needs during routine clinical visits.

OBJECTIVES

Our objectives were to pilot a digital platform that matches, links, and visualizes patient-level information and community-level deidentified data from across sectors; establish a technical infrastructure that is scalable, generalizable, and interoperable with new datasets or technologies; employ user-centered codesign principles to refine the platform's visualizations, dashboards, and alerts with community health workers, clinicians, and clinic administrators.

METHODS

We used privacy-preserving record linkage (PPRL) tools to ensure that all identifiable patient data were encrypted, only matched and displayed with consent, and never accessed or stored by the data intermediary. We used limited data sets (LDS) to share nonidentifiable patient data with the data intermediary through a health information exchange (HIE) to take advantage of existing partner agreements, technical infrastructure, and community clinical data.

RESULTS

The platform was successfully piloted in two Federally Qualified Health Clinics by 26 clinic staff. SDoH and demographic data from findhelp were successfully linked, matched, and displayed with clinical and demographic data from the HIE, Connxus. Pilot users tested the platform using real-patient data, guiding the refinement of the social and health information platform's visualizations and alerts. Users emphasized the importance of visuals and alerts that gave quick insights into individual patient SDoH needs, survey responses, and clinic-level trends in SDoH service referrals.

CONCLUSION

This pilot shows the importance of PPRL, LDS, and HIE-based data intermediaries in sharing data across sectors and service providers for scalable patient-level care coordination and community-level insights. Clinic staff are integral in designing, developing, and adopting health technologies that will enhance their ability to address SDoH needs within existing workflows without adding undue burdens or additional stress.

MediLinker: a blockchain-based decentralized health information management platform for patient-centric healthcare

Patients' control over how their health information is stored has been an ongoing issue in health informatics. Currently, most patients' health information is stored in centralized but siloed health information systems of healthcare institutions, rarely connected to or interoperable with other institutions outside of their specific health system. This centralized approach to the storage of health information is susceptible to breaches, though it can be mitigated using technology that allows for decentralized access. One promising technology that offers the possibility of decentralization, data protection, and interoperability is blockchain. In 2019, our interdisciplinary team from the University of Texas at Austin's Dell Medical School, School of Information, Department of Electrical and Computer Engineering, and Information Technology Services developed MediLinker-a blockchain-based decentralized health information management platform for patient-centric healthcare. This paper provides an overview of MediLinker and outlines its ongoing and future development and implementation. Overall, this paper contributes insights into the opportunities and challenges in developing and implementing blockchain-based technologies in healthcare.

Social Determinants of Health and ER Utilization: Role of Information Integration during COVID-19

Emergency room (ER) admissions are the front door for the utilization of a community's health resources and serve as a valuable proxy for a community health system's capacity. While recent research suggests that social determinants of health (SDOH) are important predictors of patient health outcomes, their impact on ER utilization during the COVID-19 pandemic is not well understood. Further, the role of hospital information integration in moderating the impact of SDOH on ER utilization has not received adequate attention. Utilizing longitudinal claims data from a regional health information exchange spanning six years including the COVID-19 period, we study how SDOH affects ER utilization and whether effective integration of patient health information across hospitals can moderate its impact. Our results suggest that a patient's economic well-being significantly reduces future ER utilization. The magnitude of this relationship is significant when patients are treated at hospitals with high information integration but is weaker when patients receive care at hospitals with lower levels of information integration. Instead, patients' family and social support can reduce ER utilization when they are treated at hospitals with low information integration. In other words, different dimensions of SDOH are important in low versus high information integration conditions. Furthermore, predictive modeling shows that patient visit type and prior visit history can significantly improve the predictive accuracy of ER utilization. Our research implications support efforts to develop national standards for the collection and sharing of SDOH data, and their use and interpretation for clinical decision making by healthcare providers and policy makers.

Expansion of the Community Engagement Studio Method: Deepening Community Participation in Health Care Innovation

BACKGROUND

The Community Engagement Studio (CE Studio) method has emerged as a valuable model for community participation in health innovation research, and we advance the model by expanding the timing and number of CE Studio sessions, as well as facilitation.

OBJECTIVES

The authors expanded the CE Studio method first to include five sessions corresponding to five phases of innovation: a) health experiences, b) community readiness,c) design features, d) adoption, and e) sustainability. Community experts were engaged throughout the duration of the research. Second, the authors positioned the CE Studio Team to be deeply embedded within the research team and the community of interest through community health workers.

METHODS

The expanded CE Studio method was incorporated into a federally funded research project focused on a health technology platform. The CE Studio Team held five sessions with each of four community expert panels (total of 20 sessions) based on race/ethnicity and language: African American, Asian American, English-speaking Latinx, and Spanishspeaking Latinx.

CONCLUSIONS

CE Studio sessions revealed community experts' shared and unique evolving and deepening perspectives that show promise for expanding the model.

Perceptions of Life Support and Advance Care Planning During the COVID-19 Pandemic

Background

Research Question

Study Design and Methods

Results

Interpretation

FHIRedApp: a LEAP in health information technology for promoting patient access to their medical information

Objective

Our aim is to develop a patient engagement technology that makes it easy for patients to access their own medical information and share it with others.

Materials and Methods

This paper describes our design through an adapted Community Engagement Studio methodology to identify the needs and preferences of a diverse group of Latinx, African–American, and Asian–American individuals in the community. We use Human-Centered Design to interpret these needs and preferences to build a digital app platform, using national data standards, clinical data aggregators, and privacy-preserving solutions while maintaining the security and confidentiality of patients.

Results

We designed and developed FHIRedApp, an app platform, that allows patients to access their data and to share that access as HL7^® FHIR^® application programming interfaces with third-party app developers. We accomplished 2 major tasks: first, to demonstrate the use of interoperability and authentication standards, such as HL7^® FHIR and OAuth2, to help develop patient engagement technologies, and second, to co-develop and co-design FHIRedApp with active involvement of African–American, Latinx, and Asian–American community members. Usability results show high satisfaction rates for FHIRedApp.

Conclusion

The development of FHIRedApp demonstrates how technology innovations using national interoperability standards can be informed through a methodology of community engagement and human-centered design that involves local racial and ethnic groups.

Our aim is to develop a patient engagement technology (PET) that makes it easy for patients to access their own medical information and share it with others. We adapted a methodology to identify the needs and preferences of a diverse group of Latinx, African–American, and Asian–American patients. We used Human-Centered Design to interpret these needs and preferences to build a digital app platform, using national data standards, clinical data aggregators, and privacy-preserving solutions while maintaining the security and confidentiality of patients. We designed and developed FHIRedApp, a platform that allows other applications to work on it. Patients showed high satisfaction with the use of FHIRedApp. The development of FHIRedApp demonstrates how technology innovations using national standards for exchanging data can be informed through a methodology of community engagement and human-centered design.

Assessment of structured data elements for social risk factors

OBJECTIVES

Computable social risk factor phenotypes derived from routinely collected structured electronic health record (EHR) or health information exchange (HIE) data may represent a feasible and robust approach to measuring social factors. This study convened an expert panel to identify and assess the quality of individual EHR and HIE structured data elements that could be used as components in future computable social risk factor phenotypes.

STUDY DESIGN

Technical expert panel.

METHODS

A 2-round Delphi technique included 17 experts with an in-depth knowledge of available EHR and/or HIE data. The first-round identification sessions followed a nominal group approach to generate candidate data elements that may relate to socioeconomics, cultural context, social relationships, and community context. In the second-round survey, panelists rated each data element according to overall data quality and likelihood of systematic differences in quality across populations (ie, bias).

RESULTS

Panelists identified a total of 89 structured data elements. About half of the data elements (n = 45) were related to socioeconomic characteristics. The panelists identified a diverse set of data elements. Elements used in reimbursement-related processes were generally rated as higher quality. Panelists noted that several data elements may be subject to implicit bias or reflect biased systems of care, which may limit their utility in measuring social factors.

CONCLUSIONS

Routinely collected structured data within EHR and HIE systems may reflect patient social risk factors. Identifying and assessing available data elements serves as a foundational step toward developing future computable social factor phenotypes.

Challenges encountered in comparing international policy responses to COVID-19 and their effects

BACKGROUND

A variety of policies have been implemented around the world in response to the COVID-19 pandemic. This study originally aimed to identify and compare policy responses of different countries and their effects on the pandemic. It quickly evolved into an identification of the heterogeneity among existing policies and the challenges in making meaningful comparisons of the impact of these policies.

METHODS

The process of collecting and comparing data from different sources was analysed through inductive thematic analysis to understand the obstacles that impede research designed to compare COVID-19 data and related policies.

RESULTS

We identified the following obstacles: (1) no single reputable source of information and too much noise; (2) a lack of standards for how to measure and report data across countries; (3) variations in the content, implementation and enforcement of policies; and (4) politics, instead of science, leading the efforts in pandemic management.

CONCLUSION

Heterogeneity in existing policies makes it challenging to compare the effects of various policies worldwide on the COVID-19 pandemic. Our findings call for an automatically updated informatics infrastructure across the globe for collecting and maintaining standardized data from multiple sources. There is a strong need for steadfast utilization of scientific and technical experts to inform and influence health policy. Increased investment in public health and emergency planning is essential to overcome the current pandemic, as well as future public health emergencies. Focused leadership and collaboration from world leaders in a unified mission to decrease the mortality and morbidity of the COVID-19 pandemic is imperative.

Local Health Departments' Engagement in Activities to Address Opioid Use and Abuse: The Influence of Surveillance Systems' Use

AIMS

To examine the extent to which local health departments (LHDs) conduct activities to address opioid use and abuse. To test the hypothesis that (i) LHDs' access to data from an electronic syndromic surveillance system is associated with conducting activities to address opioid use and abuse, and (ii) among those LHDs with access to syndromic surveillance data, the use of syndromic and other surveillance data on opioid-related events is associated with LHDs' report of conducting activities to address opioid use and abuse.

METHODS

Logistic regression was used to analyze data from the 2018 Forces of Change Survey of a statistically representative sample of 966 LHDs, of which 591 participated in the survey.

RESULTS

The LHDs' access to a syndromic surveillance system was significantly associated with their report of conducting activities to address opioid use and abuse. Compared with LHDs that had no surveillance systems, odds of participating in activities to address the opioid use or abuse were higher for LHDs that managed their own surveillance systems (adjusted odds ratio, AOR = 3.022, P = .03) and those who had but did not manage their own surveillance systems (AOR = 1.920, P < .01). The LHDs' use of syndromic surveillance systems (AOR = 2.98, P = .01) or other surveillance systems (AOR = 2.21, P = .03) was also associated with higher odds to participate in activities to address the opioid use or abuse (vs no such use).

CONCLUSION

The LHDs are strategically well positioned to play their role in addressing this multifaceted epidemic. Access to data or information from electronic syndromic surveillance systems that use hospital emergency department data might significantly improve LHDs' engagement in conducting activities to address opioid use and abuse within their communities while building their capacity to face the next epidemic.

Designing and testing a blockchain application for patient identity management in healthcare

OBJECTIVE

Healthcare systems suffer from a lack of interoperability that creates "data silos," causing patient linkage and data sharing problems. Blockchain technology's unique architecture provides individuals greater control over their information and may help address some of the problems related to health data. A multidisciplinary team designed and tested a blockchain application, MediLinker, as a patient-centric identity management system.

METHODS

The study used simulated data of "avatars" representing different types of patients. Thirty study participants were enrolled to visit simulated clinics, and perform various activities using MediLinker. Evaluation was based on Bouras' criteria for patient-centric identity management and on the number of errors in entry and sharing of data by participants.

RESULTS

Twenty-nine of the 30 participants completed all study activities. MediLinker fulfilled all of Bouras' criteria except for one which was not testable. A majority of data errors were due to user error, such as wrong formatting and misspellings. Generally, the number of errors decreased with time. Due to COVID-19, sprint 2 was completed using "virtual" clinic visits. The number of user errors were less in virtual visits than in personal visits.

DISCUSSION

The evaluation of MediLinker provides some evidence of the potential of a patient-centric identity management system using blockchain technology. The results showed a working system where patients have greater control over their information and can also easily provide consent for use of their data.

CONCLUSION

Blockchain applications for identity management hold great promise for use in healthcare but further research is needed before real-world adoption.

Spatial Insights for Understanding Colorectal Cancer Screening in Disproportionately Affected Populations, Central Texas, 2019

INTRODUCTION

Colorectal cancer (CRC) screening can reduce morbidity and mortality; however, important disparities exist in CRC uptake. Our study examines the associations of distance to care and frequency of using primary care and screening.

METHODS

To examine the distribution of screening geographically and according to several demographic features, we used individual patient-level data, dated September 30, 2018, from a large urban safety-net health system in Central Texas. We used spatial cluster analysis and logistic regression adjusted for age, race, sex, socioeconomic status, and health insurance status.

RESULTS

We obtained screening status data for 13,079 age-eligible patients from the health system's electronic medical records. Of those eligible, 55.1% were female, and 55.9% identified as Hispanic. Mean age was 58.1 years. Patients residing more than 20 miles from one of the system's primary care clinics was associated with lower screening rates (odds ratio [OR], 0.63; 95% CI, 0.43-0.93). Patients with higher screening rates included those who had a greater number of primary care-related (nonspecialty) visits within 1 year (OR, 6.90; 95% CI, 6.04-7.88) and those who were part of the county-level medical assistance program (OR, 1.61; 95% CI, 1.40-1.84). Spatial analysis identified an area where the level of CRC screening was particularly low.

CONCLUSION

Distance to primary care and use of primary care were associated with screening. Priorities in targeted interventions should include identifying and inviting patients with limited care engagements.

Living with Coronavirus (COVID-19): a brief report

The world will never be the same after the current COVID-19 pandemic. We may have to live with the coronavirus for a long time. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has resulted in a major burden on the global health system and economy. This report describes the current COVID-19 landscape and its socioeconomic implications. Despite the concerns for second waves of infection, gradual lifting of lockdown restrictions has occurred worldwide to relieve economic pressures and likely contributes towards possibly surging of outbreak although region wise variation exists due to several other biological factors, such as testing capacity and basic healthcare facilities among susceptible population within that region. Different prediction models have been put forth to forecast the spread of the current outbreak. However, it is challenging to perceive the precise changes happening in the real world as every time dynamics differ same as other epidemics cannot possibly be exactly superimposed to COVID-19. Currently, to decrypt the conundrum for effective antiviral drug against SARS-CoV-2 is in full swing. Due to high rate of mortality and it expeditiously spread is it decisive to understand the biological properties, clinical characteristics, epidemiology, evolution, pathogenesis for vaccine development and pathogenicity studies against the viral curb. Instant diagnostic and adequate therapeutics serve as a major intervention for the management of pandemic containment. Our study aims to analyze the impact of current measures and to suggest appropriate administrative strategic planning rather than to make somewhat authentic prediction in relation to the current scenario. Our predictive analysis study should be helpful against prevention, cure and control of the current outbreak of COVID-19 till the availability of cure or vaccine.

Effect of vitamin A as a neoadjuvant agent in chemotherapy and photodynamic therapy of Rhabdomyosarcoma cells

Combinational therapy is among the most used treatment modality's to increase cancer treatment efficacy. It may also reduce side effects, treatment time, and development of drug resistance. The effects of different analogues of vitamin A (VA) as neoadjuvant agent were observed in this study with chemotherapeutic drugs (doxorubicin and methotrexate) and photodynamic therapy (PDT) using 5-ALA and Photogem as photosensitizers in RD cells. The uptake time of photosensitizer was optimized by means of spectrophotometric measurements. Diode laser (λ = 635 nm ± 1 nm) was used as an illumination source for PDT. Responses of administered drugs were assessed by 3-(4, 5-dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium bromide (MTT) assay. VA and its analogues exert prophylactic and therapeutic effects. Protective or antagonistic effects (CI > 1) were observed in each of the case. These results propose that the use of VA as a neoadjuvant agent in combinational therapeutic modalities may reduce the efficacy of cancer treatment protocols as well as the existing side effects. Thus, VA is not the successful drug for combinational therapies and under treatment cancer patients should try to avoid its use with oxidative stress induction therapies (e.g. PDT, Radiotherapy, chemotherapy).

An association between exposure to Middle East Respiratory Syndrome (MERS) and mortality rate of Coronavirus Disease 2019 (COVID-19)

OBJECTIVE

Our objective was to find an association between exposure of a population to Middle East Respiratory Syndrome Coronavirus (MERS-CoV) and mortality rate due to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) across different countries worldwide.

MATERIALS AND METHODS

To find the relationship between exposure to MERS-CoV and mortality rate due to SARS-CoV-2, we collected and analyzed data of three possible factors that may have resulted in an exposure of a population to MERS-CoV: (1) the number of Middle East Respiratory Syndrome (MERS) cases reported among 16 countries since 2012; (2) data of MERS-CoV seroprevalence in camels across 23 countries, as working with camels increase risk of exposure to MERS-CoV; (3) data of travel history of people from 51 countries to Saudi Arabia was collected on the assumption that travel to a country where MERS is endemic, such as, Saudi Arabia, could also lead to exposure to MERS-CoV.

RESULTS

We found a significantly lower number of Coronavirus disease 2019 (COVID-19) deaths per million (deaths/M) of a population in countries that are likely to be exposed to MERS-CoV than otherwise (t-stat=3.686, p<0.01). In addition, the number of COVID-19 deaths/M of a population was significantly lower in countries that reported a higher seroprevalence of MERS-CoV in camels than otherwise (t-stat=4.5077, p<0.01). Regression analysis showed that increased travelling history to Saudi Arabia is likely to be associated with a lower mortality rate due to COVID-19.

CONCLUSIONS

This study provides empirical evidence that a population that was at an increased risk of exposure to MERS-CoV had a significantly lower mortality rate due to SARS-CoV-2, which might be due to cross-protective immunity against SARS-CoV-2 in that population because of an earlier exposure to MERS-CoV.

Applying Blockchain Technology to Address the Crisis of Trust During the COVID-19 Pandemic

BACKGROUND

The widespread death and disruption caused by the COVID-19 pandemic has revealed deficiencies of existing institutions regarding the protection of human health and well-being. Both a lack of accurate and timely data and pervasive misinformation are causing increasing harm and growing tension between data privacy and public health concerns.

OBJECTIVE

This aim of this paper is to describe how blockchain, with its distributed trust networks and cryptography-based security, can provide solutions to data-related trust problems.

METHODS

Blockchain is being applied in innovative ways that are relevant to the current COVID-19 crisis. We describe examples of the challenges faced by existing technologies to track medical supplies and infected patients and how blockchain technology applications may help in these situations.

RESULTS

This exploration of existing and potential applications of blockchain technology for medical care shows how the distributed governance structure and privacy-preserving features of blockchain can be used to create "trustless" systems that can help resolve the tension between maintaining privacy and addressing public health needs in the fight against COVID-19.

CONCLUSIONS

Blockchain relies on a distributed, robust, secure, privacy-preserving, and immutable record framework that can positively transform the nature of trust, value sharing, and transactions. A nationally coordinated effort to explore blockchain to address the deficiencies of existing systems and a partnership of academia, researchers, business, and industry are suggested to expedite the adoption of blockchain in health care.

When Going Digital Becomes a Necessity: Ensuring Older Adults' Needs for Information, Services, and Social Inclusion During COVID-19

Older adults are in triple jeopardy during COVID-19: compared with younger people, older adults are (1) more likely to develop serious conditions and experience higher mortality; (2) less likely to obtain high quality information or services online; and (3) more likely to experience social isolation and loneliness. Hybrid solutions, coupling online and offline strategies, are invaluable in ensuring the inclusion of vulnerable populations. Most of these solutions require no new inventions. Finding the financial resources for a rapid, well-coordinated implementation is the biggest challenge. Setting up the requisite support systems and digital infrastructure is important for the present and future pandemics.

Using Blockchain Technology to Mitigate Challenges in Service Access for the Homeless and Data Exchange Between Providers: Qualitative Study

BACKGROUND

In the homeless population, barriers to housing and supportive services include a lack of control or access to data. Disparate data formats and storage across multiple organizations hinder up-to-date intersystem access to records and a unified view of an individual's health and documentation history. The utility of blockchain to solve interoperability in health care is supported in recent literature, but the technology has yet to be tested in real-life conditions encompassing the complex regulatory standards in the health sector.

OBJECTIVE

This study aimed to test the feasibility and performance of a blockchain system in a homeless community to securely store and share data across a system of providers in the health care ecosystem.

METHODS

We performed a series of platform demonstrations and open-ended qualitative feedback interviews to determine the key needs and barriers to user and stakeholder adoption. Account creation and data transactions promoting organizational efficiency and improved health outcomes in this population were tested with homeless users and service providers.

RESULTS

Persons experiencing homelessness and care organizations could successfully create accounts, grant and revoke data sharing permissions, and transmit documents across a distributed network of providers. However, there were issues regarding the security of shared data, user experience and adoption, and organizational preparedness for service providers as end users. We tested a set of assumptions related to these problems within the project time frame and contractual obligations with an existing blockchain-based platform.

CONCLUSIONS

Blockchain technology provides decentralized data sharing, validation, immutability, traceability, and integration. These core features enable a secure system for the management and distribution of sensitive information. This study presents a concrete evaluation of the effectiveness of blockchain through an existing platform while revealing limitations from the perspectives of user adoption, cost-effectiveness, scalability, and regulatory frameworks.

Developing a real-time EHR-integrated SDoH clinical tool

We describe an implementation of a pilot integration to embed SDoH-based data visualizations into the EHR in real time for clinical staff treating children with asthma.

Improving childhood tuberculosis detection and treatment through facility-based screening in rural Pakistan

SETTING

Many children with tuberculosis (TB) remain undiagnosed due to the absence of services, lack of child-friendly diagnostics and underappreciation of TB as a common cause of childhood illness.

OBJECTIVE

To show the impact of systematic verbal screening and contact tracing with appropriate management services on TB case finding in pediatric populations.

DESIGN

Between October 2014 and March 2016, children were verbally screened at the pediatric out-patient departments of four public hospitals in Jamshoro District, Pakistan. Children with symptoms or risk of TB were referred for clinical evaluation and free chest X-ray and bacteriological tests. Children with TB were started on treatment and their care givers asked to bring household members to the hospital for screening.

RESULTS

Over 105 000 children were verbally screened and 5880 presumptive childhood TB patients were identified; 1417 children (prevalence 1.3%) were diagnosed with TB; 43% were female. The median age was 5 years; 82% had pulmonary TB. An additional 390 children with TB were diagnosed through contact tracing. These activities resulted in a three-fold increase in pediatric TB case notifications.

CONCLUSION

Systematic verbal screening with clinical evaluation and free diagnostics can identify children with TB who may otherwise be missed in rural health settings.

Accreditation and evaluation of veterinary medical institutes - a Pakistani perspective

The Higher Education Commission of Pakistan (HEC) is an independent, autonomous and constitutionally established institution that provides primary funding for higher education in Pakistan, which it also oversees, regulates and accredits. According to the HEC Charter: 'the HEC of Pakistan may set up national or regional evaluation councils or authorise any existing council/or similar body to carry out accreditation of institutions including their departments, facilities and disciplines by giving them appropriate ratings'. At present, 14 accreditation bodies operate under the umbrella of the HEC. Five were established under the HEC's Quality Assurance Agency, while nine councils associated with the accreditation and evaluation of medical institutes are independent bodies that were extant before the HEC was created, and are recognised by the HEC. The authors will discuss the role of the Pakistan Veterinary Medical Council (PVMC), the accreditation of veterinary institutes and associated issues of concern. They suggest that the PVMC should adopt an unbiased approach to new and established veterinary institutes to attain uniform accreditation of all veterinary institutes throughout the country. In addition, the government should consult the accreditation councils and professional bodies before setting up new institutes. The authors also suggest that, instead of placing new veterinary institutes under the aegis of non-veterinary universities, they should be made sub-campuses of established veterinary universities. In time, they will emerge as established institutes in their own right.

Using Blockchain to Create Transaction Identity for Persons Experiencing Homelessness in America: Policy Proposal

More than 500,000 people experience homelessness in America each day. Local and federal solutions to the problem have had limited success because of the fragmentation of services and lack of valid and timely information. Billions of dollars spent to provide reliable, timely, and actionable information in health care have exposed the difficulty of establishing such a system using the prevalent information technology solutions. However, relying on successful examples of the use of blockchain to help refugee populations and poor farmers internationally, we have partnered to propose an innovative solution to this problem using the case of people experiencing homelessness in Austin, Texas. This paper aims to describe one of the first applications of blockchain technology for addressing homelessness in the United States by creating a digital identity for people experiencing homelessness and engaging emergency medical services and clinical providers. The authors argue that a lack of documentation to prove personal identity and the inability to access own records are major hurdles for empowering persons experiencing homelessness to be resilient and overcome the life challenges they face. Furthermore, it is argued that this lack of information causes misdiagnosis, duplication, and fragmentation in service delivery, which can be potentially addressed by blockchain technology. Further planning for creating a program on the ground with additional funding will demonstrate the results of using blockchain technology to establish digital identity for persons experiencing homelessness.

Measuring and Managing Population Health

Health care delivery and health promotion require timely, accurate, and useful information. Nowhere are useful data more needed than population health management. Although mountains of health-related data exist, useful information is often diffuse, poorly organized, and often inaccurate and incomplete, and doesn't serve those providing health care to individual patients, managing care for groups of patients, or promoting health for communities. Information and communication technologies are rapidly evolving to enhance population health management. These tools include electronic health records, health information exchanges, patient portals and personal health records, telemedicine and virtual health tools, the internet and social media, mobile devices, and wearable sensors. We describe each of these emerging health technologies and their future opportunities for enhancing population health.

Texting for Health: An Evaluation of a Population Approach to Type 2 Diabetes Risk Reduction With a Personalized Message

txt4health is an innovative, 14-week, interactive, population-based mobile health program for individuals at risk of type 2 diabetes, developed under the Beacon Community Program in the Greater New Orleans, La., area. A comprehensive social marketing campaign sought to enroll hard-to-reach, at-risk populations using a combination of mass media and face-to-face engagement in faith-based and retail environments. Little is known about the effectiveness of social marketing for mobile technology application in the general population. A systematic evaluation of the campaign identified successes and barriers to implementing a population-based mobile health program. Face-to-face engagement helped increase program enrollment after the initial launch; otherwise, enrollment leveled off over time. Results show positive trends in reaching target populations and in the use of mobile phones to record personal health information and set goals for reducing the risk of type 2 diabetes. The lessons from the txt4health campaign can help inform the development and programmatic strategies to provide a person-level intervention using a population-level approach for individuals at risk for diabetes as well as aid in chronic disease management.

Health Information Exchange Readiness for Demonstrating Return on Investment and Quality of Care

OBJECTIVE

To study the extent to which community health information exchanges (HIEs) deliver and measure return on investment (ROI) and improvements in the quality of care.

MATERIALS AND METHODS

We surveyed operational HIEs for their characteristics, information domains, impact on quality of care, and ROI.

RESULTS

A 60 percent response rate was achieved. Two-thirds of respondents agreed that community HIEs demonstrated a positive ROI, while one-third had no opinion or disagreed. One-fourth or fewer respondents reported using various metrics to calculate ROI. Most respondents agreed that HIEs improve the quality of care, though several were not sure and were awaiting further evidence. Most respondents indicated that they did not deliver reports on quality measures (76 percent) and that data were not being used to measure quality performance of participating providers (73 percent).

DISCUSSION

Respondents from most HIEs believe that the HIEs are demonstrating a positive ROI; however, a minority of them indicated they had used or will use specific metrics to calculate ROI. HIE representatives overwhelmingly reported that they believe the HIE activities improve the quality of healthcare delivered, but only a few are using data to evaluate provider performance or generate reports on quality measures.

CONCLUSION

This study demonstrates the challenge faced by policy makers and healthcare organizations that are investing millions of dollars in HIEs that are believed to improve health outcomes and increase efficiency, but still need more time to develop the evidence to confirm that belief. Our study shows that calculating ROI for HIEs or their impact on quality of care remains a secondary priority for most HIEs. This finding raises serious questions for the sustained support of HIEs, both financially and as a policy lever, given the end of Health Information Technology for Economic and Clinical Health (HITECH) Act funding.

Evaluating the Reliability of EHR-Generated Clinical Outcomes Reports: A Case Study

Introduction:

Quality incentive programs, such as Meaningful Use, operate under the assumption that clinical quality measures can be reliably extracted from EHRs. Safety Net providers, particularly Federally Qualified Health Centers and Look-Alikes, tend to be high adopters of EHRs; however, recent reports have shown that only about 9% of FQHCs and Look-Alikes were demonstrating meaningful use as of 2013. Our experience working with the Crescent City Beacon Community (CCBC) found that many health centers relied on chart audits to report quality measures as opposed to electronically generating reports directly from their EHRs due to distrust in the data. This paper describes a step-by-step process for improving the reliability of data extracted from EHRs to increase reliability of quality measure reports, to support quality improvement, and to achieve alignment with national clinical quality reporting requirements.

Background:

Lack of standardization in data capture and reporting within EHRs drives distrust in EHR-reported data. Practices or communities attempting to achieve standardization may look to CCBC’s experience for guidance on where to start and the level of resources required in order to execute a data standardization project. During the time of this data standardization project, CCBC was launching an HIE. Lack of trust in EHR data was a driver for distrust in the HIE data.

Methods:

We present a case study where a five-step process was used to harmonize measures, reduce data errors, and increase trust in EHR clinical outcomes reports among a community of Safety Net providers using a common EHR. Primary outcomes were the incidence of reporting errors and the potential effect of error types on quality measure percentages. The activities and level of resources required to achieve these results were also documented by the CCBC program.

Findings:

Implementation of a community-wide data reporting project resulted in measure harmonization, reduced reporting burden, and error reduction in EHR-generated clinical outcomes reporting across participating clinics over a nine-month period. Increased accuracy of clinical outcomes reports provided physicians and clinical care teams with better information to guide their decision-making around quality improvement planning.

Discussion:

A number of challenges exist to achieving reliable population level quality reporting from EHRs at the practice, vendor, and community levels. Our experience demonstrates that quality measure reporting from EHRs is not a straightforward process, and it requires time and close collaboration between clinics and vendors to improve reliability of reports. Our experience found that practices valued the opportunity and step-wise process to validate their data locally (out of their EHRs) prior to reporting out of the HIE.

Conclusion and Next Steps:

Communities can achieve higher levels of confidence in quality measure reporting at the population level by establishing collaborative user groups that work with EHR vendors as partners and use technical assistance to build relationships and trust in EHR-generated reports. While this paper describes the first phase of our work around improving standardization and reliability of EHR reports, vendors should continue to explore modifications for improving data capture (at the front-end) via standardized data entry templates.

How a Beacon Community Program in New Orleans Helped Create a Better Health Care System by Building Relationships before Technology

INTRODUCTION

In the aftermath of Hurricane Katrina, much of New Orleans' healthcare infrastructure was destroyed. Initial federal funding after the storm expanded primary care services and helped set up medical homes for New Orleans' large uninsured and underinsured population. Following that, the Beacon Community in New Orleans, charged with improving health care through the use of technology, decided the best way to accomplish those goals was to build community partnerships and introduce technology improvements based on their input and on their terms. The purpose of this paper is to describe how those partnerships were wrought, including the innovative use of a conceptual framework, and how they are being sustained; how different technologies were and are being introduced; and what the results have been so far.

METHODS

Past successful community experiences, as well as a proven conceptual framework, were used to help establish community partnerships and governance structures, as well as to demonstrate their linkages. This paper represents a compilation of reports and information from key Beacon leaders, staff and providers and their firsthand experiences in setting up those structures, as well as their conclusions.

RESULTS

The community partnerships proved extremely successful in not only devising successful ways to introduce new technology into healthcare settings, but in sustaining those changes by creating a governance structure that has enough fluidity to adapt to changing circumstances.

CONCLUSIONS

Building and developing community partnerships takes time and effort; however, these relationships are necessary and essential to introducing and sustaining new technologies in a healthcare setting and should be a first step for any organization looking to accomplish such goals.

Louisiana Clinical Data Research Network: establishing an infrastructure for efficient conduct of clinical research

The state of Louisiana, like the nation as a whole, is facing the salient challenge of improving population health and efficiency of healthcare delivery. Research to inform innovations in healthcare will best enhance this effort if it is timely, efficient, and patient-centered. The Louisiana Clinical Data Research Network (LACDRN) will increase the capacity to conduct robust comparative effectiveness research by building a health information technology infrastructure that provides access to comprehensive clinical data for more than 1 million patients statewide. To ensure that network-based research best serves its end-users, the project will actively engage patients and providers as key informants and decision-makers in the implementation of LACDRN. The network's patient-centered research agenda will prioritize patients' and clinicians' needs and aim to support evidence-based decisions on the healthcare they receive and provide, to optimize patient outcomes and quality of life.

Health information exchange: metrics to address quality of care and return on investment

The purpose of this study was to find out how many health information exchanges (HIEs) are using metrics to gauge their impact and to gather examples of metrics being used by HIEs. We administered a web-based survey to a list of functioning HIEs. Valid responses were received from 18 HIEs. Most respondents were nonprofits, most had sustainable business models, and half used metrics to gauge their impact. Reduction of duplicative testing, quality improvement efforts, care coordination, and improved readmission rates were cited as having the greatest potential to show return on investment. Most respondents selected patient-centered care as having the greatest potential to show quality improvement. The major limitation of this study is the low response rate. This study suggests that there are no standard metrics used by HIEs to evaluate their impact. The HIE community needs to take the lead in developing metrics to evaluate the benefits of information exchange.

Health Care Management Training Needs in Pakistan

The management of health care organisations (HCOs) significantly determines the quality and efficiency of health care delivery in developing countries like Pakistan. HCO managers are needed to plan and execute expansion and corporatisation of private HCOs and to transform public sector charity hospitals to self-sustaining efficient organisations and private clinics into profitable ventures. The objective of this study was to assess the need for health care management training in Pakistan using semi-structured interviews of key informants in different cities. We asked experts about the existing HCO management training opportunities, demand for such skills and its impact on the future of health services delivery. Unanimous support for HCO management training emerged in the wake of dissatisfaction with limited opportunities for such training in the country. The participants agreed that trained HCO managers can help introduce modern management practices in health care service delivery, thereby making the HCOs more efficient and effective. We conclude that well-reputed management schools would be performing an important service to the improvement of the health sector in Pakistan if they can design and offer effective management training programmes for HCOs.

Medical school sexual health curriculum and training in the United States

BACKGROUND

With 19 million new sexually transmitted infections (STIs) annually and poor screening and counseling by physicians, there is a need to improve medical training in sexual health topics in the United States.

PURPOSE

To assess medical school sexual health curricula through student and faculty descriptions of training content, methods and effectiveness.

METHODS

Nationwide telephone survey of 500 fourth-year medical students (M4s) and medical school curriculum offices.

RESULTS

Many U.S. medical schools (41/92, 44%) lack formal sexual health curricula. Many medical students are uncomfortable taking sexual histories from 10-14-year-olds (87/499, 17.4%) and from adults > 75 years (119/498, 23.8%). Students who learned history-taking on patients were more likely (OR = 3.22) to be comfortable taking histories from 10-14-year-olds than those who did not. Risk reduction counseling was considered appropriate by more students than was risk avoidance counseling (99.4% vs. 74.2%, P < 0.001).

CONCLUSION

There are significant deficiencies in medical students' training on sexual health.

A temporal-analysis-based pitch estimation system for noisy speech with a comparative study of performance of recent systems

In this paper, a new system of pitch estimation is presented. The system is designed to be robust to challenging noise conditions. This robustness to the presence of noise in the signal is achieved by developing a new representation of the speech signal, based on the operation of damped harmonic oscillators (DHOs), and temporal mode analysis of their output. The resulting representation is shown to possess qualities that are only gradually degraded in the presence of noise. A harmonic grouping based system is used to estimate the pitch frequency. This method is easily extended to simultaneously track the pitch of more than one speaker. In a series of experiments the accuracy and noise robustness of the proposed system was compared with that of a number of prominent pitch estimation and tracking systems. The results show that the proposed system's overall performance is much better than any of the other systems tested, especially in the presence of very large amounts of noise. Furthermore, the proposed system is comparatively inexpensive in terms of processing and memory requirements.

Cancer urinary bladder--5 year experience at Cenar, Quetta

BACKGROUND

Purpose of this study was to see the incidence, age, sex, geographical distribution, symptoms, personal habits, signs, histo-pathology, early diagnosis and management of cases of Cancer Urinary Bladder (Ca UB) in the patients coming to CENAR, Quetta, Pakistan.

METHODS

A retrospective study was conducted at CENAR for a period of 5 years from 1st Jan. 1993 to 31st Dec. 97, in which about 100 cases of cancer of urinary bladder were included, out of which 82 patients were male and 12 were females.

RESULTS

During our 5-year period of study, 3571 new cases of cancer were registered at CENAR, out of which 100 (2.8% of total No. of cases) were of Ca UB. Hence 20 new cases of Ca UB per year were registered at CENAR. The maximum number of cases was registered in 1996.

CONCLUSION

Our study concluded that Ca UB occurs more in male with a male female ratio of 4.5:1 and a high incidence after 40 years of age. No patient below 20 was reported. Histopathologically, Transitional Cell Carcinoma was dominating (75%). Other histological types seen were squamous cell carcinoma (4%), Adenocarcinoma (3%), UD (5%) and HPNA (10%). A considerable number of patients were using different preparations of tobacco (cigarette smoking (6%), Hubble-Bubble (5%) and Niswar (Snuff) (12%). The patients were mainly treated with Radiotherapy, because at the time of reporting they were already in stage II or beyond (97%). Some patients were also treated by surgery such as TUR, partial or radical cystectomy. A few patients (6%) also received chemotherapy.

Incidence of post transplant myelodysplasia/acute leukemia in non-Hodgkin's lymphoma patients compared with Hodgkin's disease patients undergoing autologous transplantation following cyclophosphamide, carmustine, and etoposide (CBV)

Secondary malignancies, particularly myelodysplasia (MDS), are serious events following high dose therapy with autologous stem cell support. We observed a higher frequency of secondary malignancies in patients with Hodgkin's disease (HD) than in patients with non-Hodgkin's lymphoma (NHL) undergoing high dose therapy with the same non-TBI conditioning regimen. Three hundred patients with Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL) were treated with cyclophosphamide, carmustine and etoposide and autologous stem cell support from 1986 through 1994. Median follow up of survivors is 3.9 years. Five-year survival is 51% for HD and 48% for NHL. Eleven patients developed second malignancies (9/150 treated for HD vs. 2/150 treated for NHL) a median of 2.4 years from transplantation and 5.2 years from initial diagnosis. Six patients had myelodysplasia or acute leukemia (MDS/AML) and 5 had lymphomas or solid tumors. Actuarial risk of MDS/AML at five years for patients transplanted for non-Hodgkin's lymphoma is 3% (95% CI 0.6-9.6%). HD patients had significantly different pretreatment characteristics than patients with NHL. A Cox model showed that greater number of prior relapses and prior radiation therapy were significant risk factors for the development of MDS/AML. These data suggest that CBV is associated with a lower risk of secondary MDS/AML than TBI containing regimens and that much of the risk is associated with the pre-transplantation therapy. The use of autotransplantation early in the course of therapy for relapsed lymphoma might prevent some cases of MDS/AML.

Auditory habituation in young and older adults: the verbal transformation effect

In 3 experiments, auditory massed repetition was used to examine age-related differences in habituation by means of the verbal transformation paradigm. Participants heard 10 words (5 high frequency and 5 low frequency), each presented 180 times, and they reported perceived changes in the repeated words (verbal transformations). In these experiments, older adults reported fewer illusory percepts than young adults. Older adults' loss of auditory acuity and slowing of processing, stimulus degradation (in young adults), and instructions biasing the report of these illusory percepts did not account for the fewer illusory percepts reported by the older adults. These findings suggest that older adults' reduced susceptibility to habituation arises from centrally located declines in the transmission of information within the word-recognition pathway. The discussion focuses on the implications that these age-related declines may have on word identification during on-line speech perception.

Auditory habituation in young and older adults: the verbal transformation effect

In 3 experiments, auditory massed repetition was used to examine age-related differences in habituation by means of the verbal transformation paradigm. Participants heard 10 words (5 high frequency and 5 low frequency), each presented 180 times, and they reported perceived changes in the repeated words (verbal transformations). In these experiments, older adults reported fewer illusory percepts than young adults. Older adults' loss of auditory acuity and slowing of processing, stimulus degradation (in young adults), and instructions biasing the report of these illusory percepts did not account for the fewer illusory percepts reported by the older adults. These findings suggest that older adults' reduced susceptibility to habituation arises from centrally located declines in the transmission of information within the word-recognition pathway. The discussion focuses on the implications that these age-related declines may have on word identification during on-line speech perception.

Disseminated Pseudallescheria boydii infection in a nonimmunocompromised host

We present a highly unusual case of pulmonary Pseudallescheria boydii infection in a nonimmunocompromised host with a cavitating mass lesion. The diagnosis was confirmed by open lung biopsy. The patient was treated at another institution with course of amphotericin B, considered an ineffective therapy for this infection, and presented to us with direct extension and invasion of the left atrial appendage and the pulmonary artery, followed by massive pulmonary embolization and hematogenous dissemination to the liver, spleen, kidney, pancreas, and brain.

Wegener's granulomatosis and alpha1-antitrypsin-deficiency emphysema: proteinase-related diseases

Wegener's granulomatosis (WG) and alpha1-antitrypsin (alpha1-AT)-deficiency emphysema are both uncommon disorders. A relationship may exist between these diseases involving the proteinase and antiproteinase balance in the lung. A case is presented of WG and alpha1-AT-deficiency emphysema occurring in the same patient. Previous studies concerning the correlation between abnormal alpha1-AT alleles and WG are discussed. Potential mechanisms for the relationship and recommendations for screening are given.

Meningioma in four patients with human immunodeficiency virus infection

We describe four patients infected with the human immunodeficiency virus (HIV) who had development of meningiomas. In contrast to those in the general population who have meningiomas, all our patients were young men; the mean age was 40 years (range, 32 to 50). Their risk behavior for HIV was homosexuality (three patients) and intravenous drug use (one patient). The CD4+ cell count in each of the three homosexual men was less than 50/microL and was 280/microL in the drug user. Imaging studies showed enhancing lesions in three of the patients. Although each of these meningiomas could have occurred in otherwise normal young to middle-aged men, we speculate that the meningiomas may have grown in these HIV-infected hosts because of either loss of immune function or dysregulation of cytokines.