About NMPRA

NMPRA (the National Med-Peds Residents’ Association) seeks to enhance the Med-Peds specialty by: supporting and promoting resident advancement and professional opportunities; creating national connections and opportunities for residents; increasing awareness of and advocating for med-peds as a specialty; and recruiting medical students in the specialty.

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Cureus Journal

Read the latest articles from your peers.

The Med-Peds Authors Bibliography is an ongoing collaborative project of the Med-Peds Program Directors’ Association (MPPDA), the American Academy of Pediatrics/American College of Physicians Med-Peds Section, and the National Med-Peds Residents’ Association (NMPRA).

The goal of the Med-Peds Authors Bibliography project is to compile a list of peer-reviewed literature by Med-Peds trained physicians.

This is a service provided by the Med-Peds community for those inside and outside the Med-Peds community looking to find research published by Med-Peds physicians. Because of the inability to search PubMed by the clinical training of the author, this list is not designed to be inclusive of all literature published by Med-Peds physcians. It is a listed compiled by Med-Peds physicians based on their own publication and publications that they know of of other Med-Peds physicians.

We are always looking to add peer-reviwed, PubMed cited publications to add to this list.

Peer-reviewed, PubMed cited publication to this list as follows:

  • Find the references in PubMed
  • Select “Send to”
  • Select “File”
  • Select “MEDLINE” format
  • Select “Creat File”
  • Save the file as “pubmed_result (LASTNAME).txt”
  • Email the file to [email protected]

The Med-Peds Authors Bibliography contains peer-reviewed, PubMed cited refernces in MEDLINE format. The format may look weird, but it is formatted in a way that will make it easy to import into a standard reference manager like Endnote.

If you have questions, comments, or contributions regarding the Med-Peds Field Bibliography, please email [email protected].


 

 Med-Peds Authors Bibliography

 

TI – Patient characteristics associated with venous thromboembolic events: a cohort

study using pooled electronic health record data.

DP – 2012 Nov-Dec

AB – OBJECTIVE: To demonstrate the potential of de-identified clinical data from

multiple healthcare systems using different electronic health records (EHR) to be

efficiently used for very large retrospective cohort studies. 

 

TI – Case report medical eponyms: an applied clinical informatics opportunity.

DP – 2012

AB – Medical eponyms are medical words derived from people’s names. Eponyms,

especially similar sounding eponyms, may be confusing to people trying to use

them because the terms themselves do not contain physiologically descriptive

words about the condition they refer to. Through the use of electronic health

records (EHRs), embedded applied clinical informatics tools including synonyms

and pick lists that include physiologically descriptive terms associated with any

eponym appearing in the EHR can significantly enhance the correct use of medical

eponyms. Here we describe a case example of two similar sounding medical eponyms

– Wegener’s disease and Wegner’s disease – which were confused in our EHR. We

describe our solution to address this specific example and our suggestions and

accomplishments developing more generalized approaches to dealing with medical

eponyms in EHRs. Integrating brief physiologically descriptive terms with medical

eponyms provides an applied clinical informatics opportunity to improve patient

care.

 

 

TI – Implementing Black Box Warnings (BBWs) in Health Information Systems: An

Organizing Taxonomy Identifying Opportunities and Challenges.

DP – 2012

AB – OBJECTIVE: To develop a practical approach for implementing clinical decision

support (CDS) for medication black box warnings (BBWs) into health information

systems (HIS).

 TI – Correlates and trends in training satisfaction on completion of internal

medicine-pediatrics residency: a 5-year study.

DP – 2012 Apr

AB – OBJECTIVE: To examine trends in training satisfaction in graduates of combined

internal medicine-pediatrics (Med-Peds) training programs and whether curricular

elements designed to enhance the integration of the two disciplines have been

successful. STUDY DESIGN: We conducted a cross-sectional survey of all graduating

Med-Peds residents (years 2003-2007). Responses across survey years were analyzed

to identify trends. Data for all survey years was analyzed for correlations among

curricular elements, perceived adequacy of training, and preparation for future

activities. RESULTS: Overall, residents rated training time as just right for all

areas except neonatal intensive care unit training, outpatient procedures, career

planning, and office management. There was a significant upward trend in

availability of board examination reviews, Med-Peds noon conferences, and

mentoring. Residents’ ratings of their preparation for most activities increased

across the years. More residents reported being satisfied with preparation for

internal medicine than pediatric primary care practice (86% versus 83%). Career

planning seminars, mentoring, and board reviews correlated with the greatest

increase in satisfaction. CONCLUSIONS: Med-Peds graduates report a high and

increasing level of satisfaction with their preparation in multiple educational

domains. Curricular elements designed to enhance integration of the two

disciplines have a broad positive impact. Perceived pediatric practice

preparation lags behind that of internal medicine.

 

 

TI – Graduating med-peds residents’ interest in part-time employment.

DP – 2011 Sep-Oct

AB – OBJECTIVE: As part-time work is becoming more popular among the primary care specialties, we examined the demographic descriptors of med-peds residents seeking and finding part-time employment upon completion of residency training.

 

 

TI – Screening for obesity-related complications among obese children and adolescents:

1999-2008.

DP – 2011 May

AB – Obesity is becoming an increasingly prevalent problem among American children.

Screening for obesity associated comorbid conditions has been shown to be

inconsistent. The current study was undertaken to explore patterns of ordering

screening tests among obese pediatric patients. We analyzed electronic medical

records (EMR) from 69,901 patients ages 2-18 years between June 1999 and December

2008. Obese children who had documented diagnoses of obesity were identified

based on International Classification of Diseases, Ninth Revision codes.

Screening rates for glucose, liver, and lipid abnormalities were assessed.

Regression analysis was used to examine impact of patient characteristics and

temporal trends were analyzed. Of the 9,251 obese diagnosed patients identified,

22% were screened for all three included obesity-related conditions: diabetes,

liver, and lipid abnormalities; 52% were screened for glucose abnormalities; 30%

for liver abnormalities; and 41% for lipid abnormalities. Increasing BMI and age

were associated with increased rates of screening. Females and Hispanic patients

were more likely to be screened. The majority of screening was ordered under

“basic metabolic panel,” “hepatic function panel,” and “full lipid profile” for

each respective condition. The percentages of patients screened generally

increased over time, although the percentages screened for diabetes and lipid

abnormalities seemed to plateau or decrease after 2004. Even after diagnosis,

many obese patients are not receiving recommended laboratory screening tests.

Screening increased during the study period, but remains less than ideal.

Providers could improve care by more complete laboratory screening in patients

diagnosed with obesity.

 

 TI – When is family history obtained? – Lack of timely documentation of family history

among overweight and hypertensive paediatric patients.

DP – 2010 Oct

AB – AIM: Taking a detailed family history is an inexpensive way for healthcare

providers to screen patients for increased risk of various chronic conditions.

Documentation of family history, however, has been shown to be incomplete in the

majority of patient charts. The current study examines when family history is

collected within the context of the development and diagnosis of chronic

conditions in paediatrics, using hypertension and overweight/obesity as examples.

 

 

TI – Monitoring pediatric blood pressure at dental appointments.

DP – 2010 Sep-Dec

AB – Numerous studies have tracked blood pressure from adolescence into adulthood.

It is increasingly apparent that the recent increase in obesity and resultant

end-organ effects of hypertension originates in childhood. Pediatric hypertension

is a significant health concern that, if left untreated, can affect a child’s

cardiovascular, endocrine, renal, and neurologic systems. In 2004, the National

High Blood Pressure Education Program Working Group on High Blood Pressure in

Children and Adolescents recommended that bloodpressure should be monitored in

pediatric patients who are at least 3-years-old and that this procedure should be

a part of the health care visit in all health facilities, rather than just within

the medical office. The purpose of this article was to emphasize the need for

following these recommendations at oral care visits and suggest a simplified

pediatric blood pressure table that dental clinicians can use to identify

children who need referrals to medical facilities for evaluation of blood

pressure.

 

 TI – The association of continuity of care on the diagnosis of hypertension in

children and adolescents.

DP – 2009 Dec

AB – Hypertension among pediatric patients is an underdiagnosed condition. As

continuity of care has been found to increase quality of pediatric care, we

undertook this study to assess effect of continuity on diagnosis of pediatric

hypertension. This is a retrospective analysis of 774 hypertensive patients, ages

3-18 years between June 1999 and October 2007 within the MetroHealth System in

northeastern Ohio. The proportion of hypertensive patients diagnosed was assessed

using coding within the electronic medical record. Continuity was assessed using

the usual provider of care, defined as the number of visits to the most frequent

provider divided by the total number of visits in the study period. Overall

continuity did not have a statistically significant association with diagnosis

(OR 0.7, CI 0.4-1.4). Our research indicates that continuity does not

significantly affect diagnosis of hypertension in pediatric patients. Other

approaches should be investigated to improve the significant underdiagnosis of

pediatric hypertension.

 

 

TI – Simple table to identify children and adolescents needing further evaluation of

blood pressure.

DP – 2009 Jun

AB – OBJECTIVE: The goal was to create a tool to screen more easily for children and

adolescents who might have hypertension or prehypertension. METHODS: We took the

existing tables from The Fourth Report on the Diagnosis, Evaluation and Treatment

of High Blood Pressure in Children and Adolescents, which contain hundreds of

normal and abnormal blood pressure values based on gender, age, and height

percentile, and analyzed this data to develop a much simplified table based only

on gender and age. RESULTS: In our simplified table we reduced the number of

values from 476 to 64 and have only one threshold value of abnormal systolic and

diastolic blood pressure, by gender, for each year of life (ages 3 to > or =18).

This table makes it easy to identify abnormal blood pressure values in almost any

potential care or screening setting. This approach is ideal when blood pressure

is measured outside a physician’s office or even at intake in a pediatrician’s

office, when the height percentile (which is required for the use of current

tables) may not be easily obtainable. CONCLUSIONS: This screening tool can

quickly and easily identify children and adolescents whose blood pressure

readings merit further evaluation by a physician and rule out abnormal blood

pressure in children and adolescents.

 

 

TI – Characteristics of medicine-pediatrics practices: results from the national

ambulatory medical care survey.

DP – 2009 Mar

AB – BACKGROUND: Combined medicine-pediatrics (med-peds) training has existed for 40

years, yet little is known about national med-peds practices. A more

comprehensive understanding of med-peds practices is important to inform medical

students and guide evolving curricula and accreditation standards. METHOD: The

authors used data from the National Ambulatory Medical Care Survey from 2000 to

2006 to characterize the age distribution and types of visits seen by med-peds,

internal medicine, pediatric, and family physicians. RESULTS: Forty-three percent

of visits to med-peds physicians were from children < or = 18 years of age.

Compared with family physicians, med-peds physicians saw a higher proportion of

infants and toddlers or = 2 years of age (21.0% versus 3.7%; P = .002) and

children or = 18 years of age (42.9% versus 15.5%; P = .002), but they treated

fewer adults age 65 or older (13.8% versus 21.3%; P = .013). Compared with

internists, med-peds physicians saw a greater percentage of visits from adults 19

to 64 years of age (75.8% versus 61.2%) and fewer visits from patients age 65 or

older (24.2% versus 38.8%; P = .006). Med-peds physicians, like family physicians

and pediatricians, most commonly treated patients for acute problems and reported

high levels of continuity of care for patients-pediatric (93.6%) and adult

(94.6%). CONCLUSIONS: Med-peds physicians care for a considerable proportion of

pediatric patients while maintaining high levels of continuity of care for adult

and pediatric patients. Within their practices, med-peds physicians treat a

larger percentage of pediatric patients than do family physicians, but they see a

smaller percentage of elderly patients.

 

 

TI – Trends in the diagnosis of overweight and obesity in children and adolescents:

1999-2007.

DP – 2009 Jan

AB – OBJECTIVE: Pediatric overweight and obesity are increasingly prevalent problems

and have received much attention in recent years, but it is unclear whether this

publicity has affected diagnosis by clinicians. We undertook the current study to

assess trends in diagnosis rates of overweight and obesity in children. PATIENTS

AND METHODS: We analyzed electronic medical record data from 60711 patients aged

2 through 18 years with at least 1 well-child visit between June 1999 and October

2007 in a large academic medical system in northeast Ohio. Diagnosis of weight

problems among children classified as overweight and obese was assessed by using

International Classification of Diseases, Ninth Revision codes. Logistic

regression was used to examine the impact of patient characteristics on diagnosis

and to investigate trends over the study period. RESULTS: On retrospective review

of BMI measurements recorded for patients during the study period, 19% of the

children were overweight, 23% were obese, and 8% (33% of the obese patients) were

severely obese; among these, 10% of overweight patients, 54% of obese patients,

and 76% of severely obese patients had their conditions diagnosed. BMI, age, and

number of overweight visits were positively associated with diagnosis. Female

patients were more likely to have been diagnosed than male patients. Black and

Hispanic patients were more likely to have been diagnosed than white patients.

There was a statistically significant trend toward increasing diagnosis during

the study period, although the percentage of patients diagnosed per year seemed

to plateau or decrease after 2005. CONCLUSIONS: Although clear BMI definitions of

pediatric weight problems exist, a large percentage of overweight and obese

patients remain undiagnosed. Diagnosis increased during the study period but

remained low among overweight children, for whom early intervention may be more

effective. Identification of overweight and obese patients is the first step in

addressing this growing epidemic.

 

 

TI – The value of personal health record (PHR) systems.

DP – 2008

AB – Personal health records (PHRs) are a rapidly growing area of health information

technology despite a lack of significant value-based assessment.Here we present

an assessment of the potential value of PHR systems, looking at both costs and

benefits.We examine provider-tethered, payer-tethered, and third-party PHRs, as

well as idealized interoperable PHRs. An analytical model was developed that

considered eight PHR application and infrastructure functions. Our analysis

projects the initial and annual costs and annual benefits of PHRs to the entire

US over the next 10 years.This PHR analysis shows that all forms of PHRs have

initial net negative value. However, at the end of 10 years, steady state annual

net value ranging from$13 billion to -$29 billion. Interoperable PHRs provide the

most value, followed by third-party PHRs and payer-tethered PHRs also showing

positive net value. Provider-tethered PHRs constantly demonstrating negative net

value.

 

TI – A cost model for personal health records (PHRs).

DP – 2008

AB – Personal health records (PHRs) are a rapidly expanding area in medical

informatics due to the belief that they may improve healthcare delivery and

control costs of care. To truly understand the full potential value of a

technology, a cost analysis is critical.However, little evidence exists on the

value potential of PHRs, and a cost model for PHRs does not currently exist in

the literature.This paper presents a sample cost model for PHR systems, which

include PHR infrastructure and applications. We used this model to examine the

costs of provider-tethered, payer-tethered, third-party, and interoperable PHRs.

Our model projects that on a per-person basis, third-party PHRs will be the most

expensive followed by inter operable PHRs, and then provider-tethered PHRs and

payer-tethered PHRs are the least expensive. Data interfaces are a major cost

driver, thus these findings underscore the need for standards development and use

in the implementation ofPHR systems.

 

 

TI – A patient-centric taxonomy for personal health records (PHRs).

DP – 2008

AB – Today, the nascent field of personal health records (PHRs) lacks a comprehensive

taxonomy that encompasses the full range of PHRs currently in existence and what

may be possible. The Center for Information Technology Leadership (CITL) has

created a taxonomy that broadly defines a PHR as having both an infrastructure

component, which allows for data viewing and sharing, and an application

component, allowing for self-management and information exchange. The taxonomy

also accounts for different PHR architectures provider, payer, third-party, or

interoperable. This comprehensive taxonomy may help to define the field of PHRs

and provide a framework for assessing PHR value.

 

 TI – A research agenda for personal health records (PHRs).

DP – 2008 Nov-Dec

AB – Patients, policymakers, providers, payers, employers, and others have increasing

interest in using personal health records (PHRs) to improve healthcare costs,

quality, and efficiency. While organizations now invest millions of dollars in

PHRs, the best PHR architectures, value propositions, and descriptions are not

universally agreed upon. Despite widespread interest and activity, little PHR

research has been done to date, and targeted research investment in PHRs appears

inadequate. The authors reviewed the existing PHR specific literature (100

articles) and divided the articles into seven categories, of which four in

particular–evaluation of PHR functions, adoption and attitudes of healthcare

providers and patients towards PHRs, PHR related privacy and security, and PHR

architecture–present important research opportunities. We also briefly discuss

other research related to PHRs, PHR research funding sources, and PHR business

models. We believe that additional PHR research can increase the likelihood that

future PHR system deployments will beneficially impact healthcare costs, quality,

and efficiency.

 

 

TI – A new taxonomy for telehealth technologies.

DP – 2007

AB – Today, the field of telehealth lacks a comprehensive taxonomy that reflects the

variety of remote interactions, technologies used, and personnel involved. The

Center for Information Technology Leadership (CITL) has created a taxonomy that

categorizes telehealth around four factors: type of telehealth interaction,

location of the controlling medical authority, urgency of care, and timing of

communication. This comprehensive taxonomy may help to define the field of

telehealth and may help with adoption, research, and reimbursement.

 

 TI – Ambulatory electronic medical record payback analysis 7 years after

implementation in a tertiary care county medical system.

DP – 2007

AB – Electronic medical records (EMRs) are gaining increasing prominence in

healthcare, however still have low market penetration. EMR implementation cost is

a primary perceived barrier. Here we present a payback analysis on an outpatient

EMR implementation, showing capital expense recovery (net of operating costs) at

6 years and now generating $6 million yearly in direct savings for our healthcare

system.

 TI – Underdiagnosis of pediatric hypertension-an example of a new era of clinical

research enabled by electronic medical records.

DP – 2007

AB – Previously, large scale clinical research required large budgets, significant

staff, and long periods of time. Typically most of these resources were spent on

data collection to develop electronic research databases. With the proliferation

of electronic medical records this clinical research paradigm changes. Here we

present a large clinical study of pediatric hypertension (14,187 patients)

conducted through an electronic medical record without any budget and within

about 70 hours over 6 months.

 

 

TI – A framework and approach for assessing the value of personal health records

(PHRs).

DP – 2007

AB – Personal Health Records (PHRs) are a rapidly expanding area of medical

informatics due to the belief that they may improve health care delivery and

control costs of care. The PHRs in use or in development today support a myriad

of different functions, and consequently offer different value propositions. A

comprehensive value analysis of PHRs has never been conducted; such analysis is

needed to identify those PHR functions that yield the greatest value to PHR

stakeholders. Here we present a framework that could serve as a foundation for

determining the value of PHR functions and thereby help optimize PHR development.

While the value framework is specific to the domain of PHRs, the authors have

successfully applied the associated evaluation methodology in assessing other

health care information technologies.

 

 

TI – The value of provider-to-provider telehealth.

DP – 2008 Jun

AB – Telehealth has great potential to improve access to care, but its adoption in

routine healthcare has been slow. The lack of clarity about the value of

telehealth implementations has been one reason cited for this slow adoption. The

Center for Information Technology Leadership has examined the value of telehealth

encounters in which there is a provider both with the patient and at a distance

from the patient. We considered three models of telehealth: store-and-forward,

real-time video, and hybrid systems. Evidence from the literature was

extrapolated using a computer simulation, which found that the hybrid model was

the most cost effective. The simulation predicted savings of $4.3 billion per

year if hybrid telehealth systems were implemented in emergency rooms, prisons,

nursing home facilities, and physician offices across the United States. We also

conducted a sensitivity analysis to determine which factors most influence costs

and savings. Payers, providers, and policymakers should work together to remove

the barriers to the adoption of telehealth so that this cost savings can be

realized in the U.S. healthcare system.

 

 TI – The value proposition in the widespread use of telehealth.

DP – 2008

AB – Telehealth has great potential to improve access to care but its adoption in

routine health care has been slow. The lack of clarity about the value of

telehealth implementations has been one reason cited for this slow adoption. The

Center for Information Technology Leadership has examined the value of telehealth

encounters in which there is a provider both with the patient and at a distance

from the patient. We considered three models of telehealth: store-and-forward,

real-time video and hybrid systems. Evidence from the literature was extrapolated

using a simulation, which found that the hybrid model was the most cost-effective

of the three. The simulation predicted savings of $4.3 billion per year if hybrid

telehealth systems were to be implemented in emergency rooms, prisons, nursing

home facilities and physician offices across the US. We also conducted a

sensitivity analysis to determine which factors most affected costs and savings.

For all three telehealth models, the highest sensitivities were to the cost of a

face-to-face visit, the cost of a telehealth visit and the success rate of a

telehealth visit, i.e. the proportion of telehealth visits that avoided the need

for a face-to-face visit. Payers, providers and policy-makers should work

together to remove the barriers to the adoption of telehealth in order to make it

widely available to all.

 

 

TI – Health information exchange and patient safety.

DP – 2007 Dec

AB – One of the most promising advantages for health information exchange (HIE) is

improved patient safety. Up to 18% of the patient safety errors generally and as

many as 70% of adverse drug events could be eliminated if the right information

about the right patient is available at the right time. Health information

exchange makes this possible. Here we present an overview of six different ways

in which HIE can improve patient safety-improved medication information

processing, improved laboratory information processing, improved radiology

information processing, improved communication among providers, improved

communication between patients and providers, and improved public health

information processing. Within the area of improved medication information

processing we discuss drug-allergy information processing, drug-dose information

processing, drug-drug information processing, drug-diagnosis information

processing, and drug-gene information processing. We also briefly discuss HIE and

decreased patient safety as well as standards and completeness of information for

HIE and patient safety.

 

 

TI – The effect of dual training in internal medicine and pediatrics on the career

path and job search experience of pediatric graduates.

DP – 2007 Oct

AB – OBJECTIVE: To compare the job search experience and career plans of

medicine-pediatrics (med-peds) and pediatric residents. STUDY DESIGN: Annual

surveys of graduating med-peds and pediatric residents were compared from 2003

and 2004. RESULTS: The survey response rates were 58% for med-peds residents (n =

427) and 61% for pediatric residents (n = 611). Pediatric residents were more

likely to be female or an International Medical Graduate. The groups were equally

satisfied with their career choice and had equivalent debt. Med-peds residents

were more likely to seek and accept generalist and hospitalist positions.

Pediatric residents were more likely to seek subspecialty careers and research

opportunities. More than 94% of med-peds residents expected to care for pediatric

patients. Among residents seeking generalist positions, med-peds residents sent

half as many applications to get the same number of interviews and offers as

pediatric residents, were more likely to be offered their most desired position,

and were more likely to accept a position in a rural area/small town. Med-peds

residents had substantially greater starting salaries as hospitalists or

generalists compared with pediatric residents. CONCLUSION: Med-peds and pediatric

trainees differ in their career plans, although primary care is their most

popular choice. Med-peds- trained physicians have an easier job search experience

and greater market valuation.

 

 

TI – Underdiagnosis of hypertension in children and adolescents.

DP – 2007 Aug 22

AB – CONTEXT: Pediatric hypertension is increasing in prevalence with the pediatric

obesity epidemic. Diagnosis of hypertension in children is complicated because

normal and abnormal blood pressure values vary with age, sex, and height and are

therefore difficult to remember. OBJECTIVES: To determine the frequency of

undiagnosed hypertension and prehypertension and to identify patient factors

associated with this underdiagnosis. DESIGN, SETTING, AND PARTICIPANTS: A cohort

study of 14,187 children and adolescents aged 3 to 18 years who were observed at

least 3 times for well-child care between June 1999 and September 2006 in the

outpatient clinics in a large academic urban medical system in northeast Ohio.

For children and adolescents who met criteria for hypertension or prehypertension

at 3 or more well-child care visits, the proportion with a hypertension-related

International Classification of Diseases, Ninth Revision code in the diagnoses

list, problem list, or past medical history list of any visit was determined.

MAIN OUTCOME MEASURES: Proportion of children and adolescents with 3 or more

elevated age-adjusted and height-adjusted blood pressure measurements at

well-child care visits and with a diagnosis of hypertension or prehypertension

documented in the electronic medical record. Multivariate logistic regression

identified patient factors associated with a correct diagnosis. RESULTS: Of 507

children and adolescents (3.6%) who had hypertension, 131 (26%) had a diagnosis

of hypertension or elevated blood pressure documented in the electronic medical

record. Patient factors that increased the adjusted odds of a correct diagnosis

were a 1-year increase in age over age 3 (odds ratio [OR], 1.09; 95% confidence

interval [CI], 1.03-1.16), number of elevated blood pressure readings beyond 3

(OR, 1.77; 95% CI, 1.21-2.57), increase of 1% in height-for-age percentile (OR,

1.02; 95% CI, 1.01-1.03), having an obesity-related diagnosis (OR, 2.61; 95% CI,

1.49-4.55), and number of blood pressure readings in the stage 2 hypertension

range (OR, 1.68; 95% CI, 1.29-2.19). Of 485 children and adolescents (3.4%) who

had prehypertension, 55 (11%) had an appropriate diagnosis documented in the

electronic medical record. Patient factors that increased the adjusted odds of

being diagnosed with prehypertension included a 1-year increase in age over age 3

(OR, 1.21; 95% CI, 1.09-1.34) and number of elevated blood pressure readings

beyond 3 (OR, 3.07; 95% CI, 2.20-4.28). CONCLUSIONS: Hypertension and

prehypertension were frequently undiagnosed in this pediatric population. Patient

age, height, obesity-related diagnoses, and magnitude and frequency of abnormal

blood pressure readings all increased the odds of diagnosis.

 

 

TI – The next generation EKG–in vivo demonstration of noninvasive

electrocardiographic imaging during normal sinus rhythm.

DP – 2004

AB – Noninvasive, in vivo, reconstruction of epicardial electrical activity is needed

to help better study, understand, and treat electrical rhythm abnormalities.

Here, a new method for noninvasive electrocardiographic imaging is used to

reconstruct epicardial potentials in vivo during normal sinus rhythm. This method

used measured body surface potentials (BSPMs) and the relative geometry between

the body surface and epicardial surface from computed tomography (CT) to

reconstruct in vivo epicardial potentials during normal sinus rhythm. The

reconstructed epicardial potentials correlated qualitatively with those expected

for various aspects of normal sinus rhythm (NSR). This study shows that

noninvasively reconstructed epicardial potentials could provide useful

information on the electrical activity of the heart during normal activation and

repolarization sequences not otherwise available.

 

 TI – Assessing medical informatics confidence among 1st and 2nd year medical students.

DP – 2006

AB – Currently no medical informatics curriculum is required at US medical schools. In

1998 the Association of American Medical Colleges (AAMC) Medical School

Objectives Project (MSOP) identified topics for inclusion in medical school

curriculum, categorized in five domains: Life-Long Learner, Clinician,

Educator/Communicator, Researcher, and Manager. Here we present the results of a

web-based survey of 1st and 2nd year medical students at Case Western Reserve

University (Case). The survey determined the perceived skills of 1st and 2nd year

students in the five domains of medical informatics as defined by the AAMC.

 

TI – Comparing perceptions and use of a commercial electronic medical record (EMR)

between primary care and subspecialty physicians.

 DP – 2006

 

 

TI – Evaluation of a commercial electronic medical record (EMR) by primary care

physicians 5 years after implementation.

DP – 2005

AB – Electronic medical records (EMRs) are gaining increasing prominence in the

delivery of healthcare, although the focus is primarily on deploying EMRs.

Relatively little research has studied the post-implementation of commercial

EMRs. Here we present the results of a web-based survey of all the primary care

clinicians in our university affiliated, tertiary care health system. The survey

evaluated primary care clinician demographics, usage, and ideas for enhancement

of the EpicCare EMR, five year after its initial deployment throughout our

healthcare system.

 

 

TI – Training experiences of U.S. combined internal medicine and pediatrics residents.

DP – 2006 May

AB – PURPOSE: To investigate the demographics and training experiences of internal

medicine and pediatrics (med-peds) physicians. METHOD: A cross-sectional survey

addressing demographics, training experiences, and career plans of fourth-year

residents graduating from combined internal medicine and pediatrics programs that

were identified in the American Academy of Pediatrics database was initiated in

May 2003. Questionnaires were mailed up to four times to nonresponders through

August 2003. RESULTS: Valid responses were received from 212 of the 340

graduating residents (62% response rate). The majority (186/208 [89%]) reported

that they would choose med-peds training again. Career planning (135/210 [64%]),

office management (173/212 [82%]), and outpatient procedures (155/211 [73%]) were

the only areas where the majority desired more training. Neonatal intensive care

training was the only topic area that the majority of residents (142/212 [67%])

reported could have been carried out in less time. Nearly all residents (183/196

[93%]) planned to care for children and adults. Residents’ self-assessment of
their preparation was good to excellent for evidence-based medicine (192/210

[91%]), caring for patients with special health care needs (179/209 [86%]), and
use of information technology (169/208 [81%]). Residents felt equally well

prepared for postgraduate activities in internal medicine and pediatrics primary

care (170/212 [80%] versus 163/211 [77%], p = .305, NS) and internal medicine and

pediatric fellowships (186/207 [90%] versus 181/208 [87%], p = .058, NS). Only

112 of 209 residents (54%) felt their preparation for research was good to

excellent. CONCLUSIONS: The study findings suggest that med-peds residents are

satisfied with their decision to train in med-peds and with their level of

preparation. They feel equally well prepared to care for adults and children, and

well prepared to care for patients that may transition to adulthood with complex

needs, to assess evidence, and to use information technology.

 

 TI – Combination therapy: medicated urethral system for erection enhances sexual

satisfaction in sildenafil citrate failure following nerve-sparing radical

prostatectomy.

DP – 2005 Nov-Dec

AB – The objective of our study was to assess the effectiveness of combining medicated

urethral system for erection (MUSE) with sildenafil citrate in men unsatisfied

with the sildenafil alone. Baseline and follow-up data from 23 patients (mean

age, 62.5 +/- 5.23 years) unsatisfied with the use of the sildenafil citrate

alone for the treatment of erectile dysfunction following nerve-sparing radical

prostatectomy (mean use, 4 attempts/100-mg dose) was obtained. All patients

started oral sildenafil citrate more than 6 months after radical prostatectomy.

Combination therapy was initiated using 100 mg sildenafil citrate orally 1 hour

prior to intercourse. Patients used combination therapy for a minimum of 4

attempts prior to assessment with the Sexual Health Inventory of Men

(International Index for Erectile Function-5) and visual analog scale to gauge

rigidity (0-100). The effect of therapy on the total International Index for

Erectile Function (IIEF) score and penile rigidity score was assessed. Of the 23

patients, 4 (17%) had no improvement with the addition of medicated urethral

system for erection and discontinued the drug, while 19 (83%) reported

improvement with the penile rigidity and sexual satisfaction. The IIEF scores of

these 19 patients showed significant improvements in each sexual domain, and the

patients reported that erection was sufficient for vaginal penetration 80% of the

time. Rigidity scores on a scale of 0-100 with sildenafil alone averaged 38%

(23-53) for men and 46% (26-67) for their partners. With the addition of MUSE,

scores increased to 76% for men and 62% for their partners. We conclude that the

addition of MUSE to sildenafil improved sexual satisfaction and penile rigidity

in patients unsatisfied with sildenafil alone.

 

 

TI – A Web-based clinical curriculum on the cardiac exam.

DP – 2001 May

 

 

TI – A field-compatible method for interpolating biopotentials.

DP – 1998 Jan-Feb

AB – Mapping of bioelectric potentials over a given surface (e.g., the torso surface,

the scalp) often requires interpolation of potentials into regions of missing

data. Existing interpolation methods introduce significant errors when

interpolating into large regions of high potential gradients, due mostly to their

incompatibility with the properties of the three-dimensional (3D) potential

field. In this paper, an interpolation method, inverse-forward (IF)

interpolation, was developed to be consistent with Laplace’s equation that

governs the 3D field in the volume conductor bounded by the mapped surface. This

method is evaluated in an experimental heart-torso preparation in the context of

electrocardiographic body surface potential mapping. Results demonstrate that IF

interpolation is able to recreate major potential features such as a potential

minimum and high potential gradients within a large region of missing data. Other

commonly used interpolation methods failed to reconstruct major potential

features or preserve high potential gradients. An example of IF interpolation

with patient data is provided to illustrate its applicability in the actual

clinical setting. Application of IF interpolation in the context of noninvasive

reconstruction of epicardial potentials (the “inverse problem”) is also examined.

 

 

TI – Index of suspicion.

DP – 2008 Jan

 

 

TI – Benchmarks for support of internal medicine-pediatrics programs.

DP – 2007 May

 

 

TI – BRIEF REPORT: Health Care Provided by Program Directors to Their Resident

Physicians and Families.

DP – 2006 Sep 18

AB – BACKGROUND: Who provides health care to resident physicians is not well studied.

OBJECTIVE: To determine whether residency program directors (PDs) provide health

care to their own residents and residents’ families. DESIGN: An anonymous survey

mailed to 1,345 PDs in Emergency Medicine, Family Medicine, Internal Medicine,

Medicine-Pediatrics, and Obstetrics-Gynecology in the United States in 2003.

RESULTS: Six hundred nineteen PDs (46%) responded. Half had taken care of their

own residents for acute conditions. Less commonly, directors had written

prescriptions for acute (40%) or chronic needs (15%) or provided ongoing care

(22%). Only 3% believed this conflicted with their ability to be effective

directors. Responders more likely to provide future care to residents considered

this kind of care generally appropriate (P<.001), or appropriate under certain

circumstances (P<.001). Most of these spent >/=31% of their time seeing patients.

There was no difference among types of programs, gender of the director, or the

years as director. Twenty-five percent of directors provided care to their

residents’ families. CONCLUSIONS: Substantial numbers of directors provided

health care to their own residents. Few believed this conflicted with their

director role. We believe organizations of PDs should develop positions about

this practice.

 

 

TI – As the child with chronic disease grows up: transitioning adolescents with

special health care needs to adult-centered health care.

DP – 2003 Jun

AB – The purpose of this article is to inform readers of the Delaware Medical Journal

about the concept of transitional care for adolescents and young adults with

chronic health care needs. This is a topic that has recently received national

attention and was the subject of a supplement to Pediatrics in December 2002. The

concept of transitional care bears special importance in Delaware as every year

hundreds of children with chronic disease turn 18 and leave their pediatric

providers. It is uncertain that these children resume their care with an adult

health care provider, and there is almost always some lag in time as patients

attempt to find an adult provider who is knowledgeable about their condition and

willing to assume them as a patient. An even greater uncertainty is whether or

not adult providers are prepared to take care of this new generation of adults

with cyanotic congenital heart disease, spina bifida, cerebral palsy, and other

conditions. This article explores some of these ideas and discusses what is

available in the transition literature and where to go from here.

 

 

TI – Using patients with cancer to educate residents about giving bad news.

DP – 2003 Spring

 

 

TI – Graduating med-peds residents’ interest in part-time employment.

DP – 2011 Sep-Oct

AB – OBJECTIVE: As part-time work is becoming more popular among the primary care

specialties, we examined the demographic descriptors of med-peds residents

seeking and finding part-time employment upon completion of residency training.

METHODS: As part of the 2006 annual American Academy of Pediatrics (AAP)

Graduating Med-Peds Residents Survey, we surveyed the graduating residents of all

med-peds programs about their interest in and plans for part-time employment. A

total of 199 (60%) of the residents responded. RESULTS: Of the resident

respondents applying for nonfellowship jobs, 19% sought part-time positions and

10% actually accepted a part-time position. Female residents were significantly

more likely than male residents to apply for part-time jobs (26% vs. 7%, P =

.034). Sixty percent of female residents immediately seeking work and 58% of

those going on to fellowship reported an interest in arranging a part-time or

reduced-hours position at some point in the next 5 years. CONCLUSIONS: Part-time

employment among med-peds residents applying for nonfellowship positions after

graduation is similar to the current incidence of part-time employment in other

fields of primary care. A much higher percentage of med-peds residents are

interested in arranging part-time work within 5 years after graduation. This

strong interest in part-time work has many implications for the primary care

workforce.

 

 TI – Screening for obesity-related complications among obese children and adolescents:

1999-2008.

DP – 2011 May

AB – Obesity is becoming an increasingly prevalent problem among American children.

Screening for obesity associated comorbid conditions has been shown to be

inconsistent. The current study was undertaken to explore patterns of ordering

screening tests among obese pediatric patients. We analyzed electronic medical

records (EMR) from 69,901 patients ages 2-18 years between June 1999 and December

2008. Obese children who had documented diagnoses of obesity were identified

based on International Classification of Diseases, Ninth Revision codes.

Screening rates for glucose, liver, and lipid abnormalities were assessed.

Regression analysis was used to examine impact of patient characteristics and

temporal trends were analyzed. Of the 9,251 obese diagnosed patients identified,

22% were screened for all three included obesity-related conditions: diabetes,

liver, and lipid abnormalities; 52% were screened for glucose abnormalities; 30%

for liver abnormalities; and 41% for lipid abnormalities. Increasing BMI and age

were associated with increased rates of screening. Females and Hispanic patients

were more likely to be screened. The majority of screening was ordered under

“basic metabolic panel,” “hepatic function panel,” and “full lipid profile” for

each respective condition. The percentages of patients screened generally

increased over time, although the percentages screened for diabetes and lipid

abnormalities seemed to plateau or decrease after 2004. Even after diagnosis,

many obese patients are not receiving recommended laboratory screening tests.

Screening increased during the study period, but remains less than ideal.

Providers could improve care by more complete laboratory screening in patients

diagnosed with obesity.

 

 

TI – When is family history obtained? – Lack of timely documentation of family history

among overweight and hypertensive paediatric patients.

DP – 2010 Oct

AB – AIM: Taking a detailed family history is an inexpensive way for healthcare

providers to screen patients for increased risk of various chronic conditions.

Documentation of family history, however, has been shown to be incomplete in the

majority of patient charts. The current study examines when family history is

collected within the context of the development and diagnosis of chronic

conditions in paediatrics, using hypertension and overweight/obesity as examples.

METHODS: We analysed family history data from the electronic medical records of

5485 overweight/obese and 774 hypertensive children and adolescents in a large,

urban medical system in northeast Ohio. Manual review of 200 charts was also

performed. RESULTS: Family history information was entered prior to the

development of hypertension in 13.5% of hypertensive patients with a family

history of hypertension, and it was entered prior to the development of abnormal

weight in 35.5% of overweight/obese patients with a family history of obesity or

a related condition. Of patients with a relevant family history who received an

actual diagnosis for either of these conditions, only 16.7% of hypertensive and

33.3% of overweight/obese patients had this family history documented prior to

diagnosis. CONCLUSIONS: These results imply that paediatric providers may not use

family history as a screening tool for assessing future risk of obesity and

hypertension, but instead gather this information after these chronic conditions

have developed, making it difficult to implement preventative or screening

strategies based on familial risk.

 

 

TI – The association of continuity of care on the diagnosis of hypertension in

children and adolescents.

DP – 2009 Dec

AB – Hypertension among pediatric patients is an underdiagnosed condition. As

continuity of care has been found to increase quality of pediatric care, we

undertook this study to assess effect of continuity on diagnosis of pediatric

hypertension. This is a retrospective analysis of 774 hypertensive patients, ages

3-18 years between June 1999 and October 2007 within the MetroHealth System in

northeastern Ohio. The proportion of hypertensive patients diagnosed was assessed

using coding within the electronic medical record. Continuity was assessed using

the usual provider of care, defined as the number of visits to the most frequent

provider divided by the total number of visits in the study period. Overall

continuity did not have a statistically significant association with diagnosis

(OR 0.7, CI 0.4-1.4). Our research indicates that continuity does not

significantly affect diagnosis of hypertension in pediatric patients. Other

approaches should be investigated to improve the significant underdiagnosis of

pediatric hypertension.

 

 

TI – Simple table to identify children and adolescents needing further evaluation of

blood pressure.

DP – 2009 Jun

AB – OBJECTIVE: The goal was to create a tool to screen more easily for children and

adolescents who might have hypertension or prehypertension. METHODS: We took the

existing tables from The Fourth Report on the Diagnosis, Evaluation and Treatment

of High Blood Pressure in Children and Adolescents, which contain hundreds of

normal and abnormal blood pressure values based on gender, age, and height

percentile, and analyzed this data to develop a much simplified table based only

on gender and age. RESULTS: In our simplified table we reduced the number of

values from 476 to 64 and have only one threshold value of abnormal systolic and

diastolic blood pressure, by gender, for each year of life (ages 3 to > or =18).

This table makes it easy to identify abnormal blood pressure values in almost any

potential care or screening setting. This approach is ideal when blood pressure

is measured outside a physician’s office or even at intake in a pediatrician’s

office, when the height percentile (which is required for the use of current

tables) may not be easily obtainable. CONCLUSIONS: This screening tool can

quickly and easily identify children and adolescents whose blood pressure

readings merit further evaluation by a physician and rule out abnormal blood

pressure in children and adolescents.

 

 

TI – Characteristics of medicine-pediatrics practices: results from the national

ambulatory medical care survey.

DP – 2009 Mar

AB – BACKGROUND: Combined medicine-pediatrics (med-peds) training has existed for 40

years, yet little is known about national med-peds practices. A more

comprehensive understanding of med-peds practices is important to inform medical

students and guide evolving curricula and accreditation standards. METHOD: The

authors used data from the National Ambulatory Medical Care Survey from 2000 to

2006 to characterize the age distribution and types of visits seen by med-peds,

internal medicine, pediatric, and family physicians. RESULTS: Forty-three percent

of visits to med-peds physicians were from children < or = 18 years of age.

Compared with family physicians, med-peds physicians saw a higher proportion of

infants and toddlers < or = 2 years of age (21.0% versus 3.7%; P = .002) and

children < or = 18 years of age (42.9% versus 15.5%; P = .002), but they treated

fewer adults age 65 or older (13.8% versus 21.3%; P = .013). Compared with

internists, med-peds physicians saw a greater percentage of visits from adults 19

to 64 years of age (75.8% versus 61.2%) and fewer visits from patients age 65 or

older (24.2% versus 38.8%; P = .006). Med-peds physicians, like family physicians

and pediatricians, most commonly treated patients for acute problems and reported

high levels of continuity of care for patients-pediatric (93.6%) and adult

(94.6%). CONCLUSIONS: Med-peds physicians care for a considerable proportion of

pediatric patients while maintaining high levels of continuity of care for adult

and pediatric patients. Within their practices, med-peds physicians treat a

larger percentage of pediatric patients than do family physicians, but they see a

smaller percentage of elderly patients.

 

 

TI – Trends in the diagnosis of overweight and obesity in children and adolescents:

1999-2007.

DP – 2009 Jan

AB – OBJECTIVE: Pediatric overweight and obesity are increasingly prevalent problems

and have received much attention in recent years, but it is unclear whether this

publicity has affected diagnosis by clinicians. We undertook the current study to

assess trends in diagnosis rates of overweight and obesity in children. PATIENTS

AND METHODS: We analyzed electronic medical record data from 60711 patients aged

2 through 18 years with at least 1 well-child visit between June 1999 and October

2007 in a large academic medical system in northeast Ohio. Diagnosis of weight

problems among children classified as overweight and obese was assessed by using

International Classification of Diseases, Ninth Revision codes. Logistic

regression was used to examine the impact of patient characteristics on diagnosis

and to investigate trends over the study period. RESULTS: On retrospective review

of BMI measurements recorded for patients during the study period, 19% of the

children were overweight, 23% were obese, and 8% (33% of the obese patients) were

severely obese; among these, 10% of overweight patients, 54% of obese patients,

and 76% of severely obese patients had their conditions diagnosed. BMI, age, and

number of overweight visits were positively associated with diagnosis. Female

patients were more likely to have been diagnosed than male patients. Black and

Hispanic patients were more likely to have been diagnosed than white patients.

There was a statistically significant trend toward increasing diagnosis during

the study period, although the percentage of patients diagnosed per year seemed

to plateau or decrease after 2005. CONCLUSIONS: Although clear BMI definitions of

pediatric weight problems exist, a large percentage of overweight and obese

patients remain undiagnosed. Diagnosis increased during the study period but

remained low among overweight children, for whom early intervention may be more

effective. Identification of overweight and obese patients is the first step in

addressing this growing epidemic.

 

 

TI – The value of personal health record (PHR) systems.

DP – 2008

AB – Personal health records (PHRs) are a rapidly growing area of health information

technology despite a lack of significant value-based assessment.Here we present

an assessment of the potential value of PHR systems, looking at both costs and

benefits.We examine provider-tethered, payer-tethered, and third-party PHRs, as

well as idealized interoperable PHRs. An analytical model was developed that

considered eight PHR application and infrastructure functions. Our analysis

projects the initial and annual costs and annual benefits of PHRs to the entire

US over the next 10 years.This PHR analysis shows that all forms of PHRs have

initial net negative value. However, at the end of 10 years, steady state annual

net value ranging from$13 billion to -$29 billion. Interoperable PHRs provide the

most value, followed by third-party PHRs and payer-tethered PHRs also showing

positive net value. Provider-tethered PHRs constantly demonstrating negative net

value.

 

 

TI – A cost model for personal health records (PHRs).

DP – 2008

AB – Personal health records (PHRs) are a rapidly expanding area in medical

informatics due to the belief that they may improve healthcare delivery and

control costs of care. To truly understand the full potential value of a

technology, a cost analysis is critical.However, little evidence exists on the

value potential of PHRs, and a cost model for PHRs does not currently exist in

the literature.This paper presents a sample cost model for PHR systems, which

include PHR infrastructure and applications. We used this model to examine the

costs of provider-tethered, payer-tethered, third-party, and interoperable PHRs.

Our model projects that on a per-person basis, third-party PHRs will be the most

expensive followed by inter operable PHRs, and then provider-tethered PHRs and

payer-tethered PHRs are the least expensive. Data interfaces are a major cost

driver, thus these findings underscore the need for standards development and use

in the implementation ofPHR systems.

 

 

TI – A patient-centric taxonomy for personal health records (PHRs).

DP – 2008

AB – Today, the nascent field of personal health records (PHRs) lacks a comprehensive

taxonomy that encompasses the full range of PHRs currently in existence and what

may be possible. The Center for Information Technology Leadership (CITL) has

created a taxonomy that broadly defines a PHR as having both an infrastructure

component, which allows for data viewing and sharing, and an application

component, allowing for self-management and information exchange. The taxonomy

also accounts for different PHR architectures provider, payer, third-party, or

interoperable. This comprehensive taxonomy may help to define the field of PHRs

and provide a framework for assessing PHR value.

 

TI – A research agenda for personal health records (PHRs).

DP – 2008 Nov-Dec

AB – Patients, policymakers, providers, payers, employers, and others have increasing

interest in using personal health records (PHRs) to improve healthcare costs,

quality, and efficiency. While organizations now invest millions of dollars in

PHRs, the best PHR architectures, value propositions, and descriptions are not

universally agreed upon. Despite widespread interest and activity, little PHR

research has been done to date, and targeted research investment in PHRs appears

inadequate. The authors reviewed the existing PHR specific literature (100

articles) and divided the articles into seven categories, of which four in

particular–evaluation of PHR functions, adoption and attitudes of healthcare

providers and patients towards PHRs, PHR related privacy and security, and PHR

architecture–present important research opportunities. We also briefly discuss

other research related to PHRs, PHR research funding sources, and PHR business

models. We believe that additional PHR research can increase the likelihood that

future PHR system deployments will beneficially impact healthcare costs, quality,

and efficiency.

 

 

TI – A new taxonomy for telehealth technologies.

DP – 2007

AB – Today, the field of telehealth lacks a comprehensive taxonomy that reflects the

variety of remote interactions, technologies used, and personnel involved. The

Center for Information Technology Leadership (CITL) has created a taxonomy that

categorizes telehealth around four factors: type of telehealth interaction,

location of the controlling medical authority, urgency of care, and timing of

communication. This comprehensive taxonomy may help to define the field of

telehealth and may help with adoption, research, and reimbursement.

 

 

TI – Ambulatory electronic medical record payback analysis 7 years after

implementation in a tertiary care county medical system.

DP – 2007

AB – Electronic medical records (EMRs) are gaining increasing prominence in

healthcare, however still have low market penetration. EMR implementation cost is

a primary perceived barrier. Here we present a payback analysis on an outpatient

EMR implementation, showing capital expense recovery (net of operating costs) at

6 years and now generating $6 million yearly in direct savings for our healthcare

system.

 

 

TI – Underdiagnosis of pediatric hypertension-an example of a new era of clinical

research enabled by electronic medical records.

DP – 2007

AB – Previously, large scale clinical research required large budgets, significant

staff, and long periods of time. Typically most of these resources were spent on

data collection to develop electronic research databases. With the proliferation

of electronic medical records this clinical research paradigm changes. Here we

present a large clinical study of pediatric hypertension (14,187 patients)

conducted through an electronic medical record without any budget and within

about 70 hours over 6 months.

 

 

TI – A framework and approach for assessing the value of personal health records

(PHRs).

DP – 2007

AB – Personal Health Records (PHRs) are a rapidly expanding area of medical

informatics due to the belief that they may improve health care delivery and

control costs of care. The PHRs in use or in development today support a myriad

of different functions, and consequently offer different value propositions. A

comprehensive value analysis of PHRs has never been conducted; such analysis is

needed to identify those PHR functions that yield the greatest value to PHR

stakeholders. Here we present a framework that could serve as a foundation for determining the value of PHR functions and thereby help optimize PHR development.

While the value framework is specific to the domain of PHRs, the authors have successfully applied the associated evaluation methodology in assessing other health care information technologies.

 

 

TI – The value of provider-to-provider telehealth.

DP – 2008 Jun

AB – Telehealth has great potential to improve access to care, but its adoption in

routine healthcare has been slow. The lack of clarity about the value of

telehealth implementations has been one reason cited for this slow adoption. The

Center for Information Technology Leadership has examined the value of telehealth

encounters in which there is a provider both with the patient and at a distance

from the patient. We considered three models of telehealth: store-and-forward,

real-time video, and hybrid systems. Evidence from the literature was

extrapolated using a computer simulation, which found that the hybrid model was

the most cost effective. The simulation predicted savings of $4.3 billion per

year if hybrid telehealth systems were implemented in emergency rooms, prisons,

nursing home facilities, and physician offices across the United States. We also

conducted a sensitivity analysis to determine which factors most influence costs

and savings. Payers, providers, and policymakers should work together to remove

the barriers to the adoption of telehealth so that this cost savings can be

realized in the U.S. healthcare system.

 

TI – The value proposition in the widespread use of telehealth.

DP – 2008

AB – Telehealth has great potential to improve access to care but its adoption in

routine health care has been slow. The lack of clarity about the value of

telehealth implementations has been one reason cited for this slow adoption. The

Center for Information Technology Leadership has examined the value of telehealth

encounters in which there is a provider both with the patient and at a distance

from the patient. We considered three models of telehealth: store-and-forward,

real-time video and hybrid systems. Evidence from the literature was extrapolated

using a simulation, which found that the hybrid model was the most cost-effective

of the three. The simulation predicted savings of $4.3 billion per year if hybrid

telehealth systems were to be implemented in emergency rooms, prisons, nursing

home facilities and physician offices across the US. We also conducted a

sensitivity analysis to determine which factors most affected costs and savings.

For all three telehealth models, the highest sensitivities were to the cost of a

face-to-face visit, the cost of a telehealth visit and the success rate of a

telehealth visit, i.e. the proportion of telehealth visits that avoided the need

for a face-to-face visit. Payers, providers and policy-makers should work

together to remove the barriers to the adoption of telehealth in order to make it

widely available to all.

 

 

TI – Health information exchange and patient safety.

DP – 2007 Dec

AB – One of the most promising advantages for health information exchange (HIE) is

improved patient safety. Up to 18% of the patient safety errors generally and as

many as 70% of adverse drug events could be eliminated if the right information

about the right patient is available at the right time. Health information

exchange makes this possible. Here we present an overview of six different ways

in which HIE can improve patient safety-improved medication information

processing, improved laboratory information processing, improved radiology

information processing, improved communication among providers, improved

communication between patients and providers, and improved public health

information processing. Within the area of improved medication information

processing we discuss drug-allergy information processing, drug-dose information

processing, drug-drug information processing, drug-diagnosis information

processing, and drug-gene information processing. We also briefly discuss HIE and

decreased patient safety as well as standards and completeness of information for

HIE and patient safety.

 

 

TI – The effect of dual training in internal medicine and pediatrics on the career

path and job search experience of pediatric graduates.

DP – 2007 Oct

AB – OBJECTIVE: To compare the job search experience and career plans of

medicine-pediatrics (med-peds) and pediatric residents. STUDY DESIGN: Annual

surveys of graduating med-peds and pediatric residents were compared from 2003

and 2004. RESULTS: The survey response rates were 58% for med-peds residents (n =

427) and 61% for pediatric residents (n = 611). Pediatric residents were more

likely to be female or an International Medical Graduate. The groups were equally

satisfied with their career choice and had equivalent debt. Med-peds residents

were more likely to seek and accept generalist and hospitalist positions.

Pediatric residents were more likely to seek subspecialty careers and research

opportunities. More than 94% of med-peds residents expected to care for pediatric

patients. Among residents seeking generalist positions, med-peds residents sent

half as many applications to get the same number of interviews and offers as

pediatric residents, were more likely to be offered their most desired position,

and were more likely to accept a position in a rural area/small town. Med-peds

residents had substantially greater starting salaries as hospitalists or

generalists compared with pediatric residents. CONCLUSION: Med-peds and pediatric

trainees differ in their career plans, although primary care is their most

popular choice. Med-peds- trained physicians have an easier job search experience

and greater market valuation.

 

TI – Underdiagnosis of hypertension in children and adolescents.

DP – 2007 Aug 22

AB – CONTEXT: Pediatric hypertension is increasing in prevalence with the pediatric

obesity epidemic. Diagnosis of hypertension in children is complicated because

normal and abnormal blood pressure values vary with age, sex, and height and are

therefore difficult to remember. OBJECTIVES: To determine the frequency of

undiagnosed hypertension and prehypertension and to identify patient factors

associated with this underdiagnosis. DESIGN, SETTING, AND PARTICIPANTS: A cohort

study of 14,187 children and adolescents aged 3 to 18 years who were observed at

least 3 times for well-child care between June 1999 and September 2006 in the

outpatient clinics in a large academic urban medical system in northeast Ohio.

For children and adolescents who met criteria for hypertension or prehypertension

at 3 or more well-child care visits, the proportion with a hypertension-related

International Classification of Diseases, Ninth Revision code in the diagnoses

list, problem list, or past medical history list of any visit was determined.

MAIN OUTCOME MEASURES: Proportion of children and adolescents with 3 or more

elevated age-adjusted and height-adjusted blood pressure measurements at

well-child care visits and with a diagnosis of hypertension or prehypertension

documented in the electronic medical record. Multivariate logistic regression

identified patient factors associated with a correct diagnosis. RESULTS: Of 507

children and adolescents (3.6%) who had hypertension, 131 (26%) had a diagnosis

of hypertension or elevated blood pressure documented in the electronic medical

record. Patient factors that increased the adjusted odds of a correct diagnosis

were a 1-year increase in age over age 3 (odds ratio [OR], 1.09; 95% confidence

interval [CI], 1.03-1.16), number of elevated blood pressure readings beyond 3

(OR, 1.77; 95% CI, 1.21-2.57), increase of 1% in height-for-age percentile (OR,

1.02; 95% CI, 1.01-1.03), having an obesity-related diagnosis (OR, 2.61; 95% CI,

1.49-4.55), and number of blood pressure readings in the stage 2 hypertension

range (OR, 1.68; 95% CI, 1.29-2.19). Of 485 children and adolescents (3.4%) who

had prehypertension, 55 (11%) had an appropriate diagnosis documented in the

electronic medical record. Patient factors that increased the adjusted odds of

being diagnosed with prehypertension included a 1-year increase in age over age 3

(OR, 1.21; 95% CI, 1.09-1.34) and number of elevated blood pressure readings

beyond 3 (OR, 3.07; 95% CI, 2.20-4.28). CONCLUSIONS: Hypertension and

prehypertension were frequently undiagnosed in this pediatric population. Patient

age, height, obesity-related diagnoses, and magnitude and frequency of abnormal

blood pressure readings all increased the odds of diagnosis.

 

 

TI – The next generation EKG–in vivo demonstration of noninvasive

electrocardiographic imaging during normal sinus rhythm.

DP – 2004

AB – Noninvasive, in vivo, reconstruction of epicardial electrical activity is needed

to help better study, understand, and treat electrical rhythm abnormalities.

Here, a new method for noninvasive electrocardiographic imaging is used to

reconstruct epicardial potentials in vivo during normal sinus rhythm. This method

used measured body surface potentials (BSPMs) and the relative geometry between

the body surface and epicardial surface from computed tomography (CT) to

reconstruct in vivo epicardial potentials during normal sinus rhythm. The

reconstructed epicardial potentials correlated qualitatively with those expected

for various aspects of normal sinus rhythm (NSR). This study shows that

noninvasively reconstructed epicardial potentials could provide useful

information on the electrical activity of the heart during normal activation and

repolarization sequences not otherwise available.

 

 

TI – Assessing medical informatics confidence among 1st and 2nd year medical students.

DP – 2006

AB – Currently no medical informatics curriculum is required at US medical schools. In

1998 the Association of American Medical Colleges (AAMC) Medical School

Objectives Project (MSOP) identified topics for inclusion in medical school

curriculum, categorized in five domains: Life-Long Learner, Clinician,

Educator/Communicator, Researcher, and Manager. Here we present the results of a

web-based survey of 1st and 2nd year medical students at Case Western Reserve

University (Case). The survey determined the perceived skills of 1st and 2nd year

students in the five domains of medical informatics as defined by the AAMC.

 

 

TI – Comparing perceptions and use of a commercial electronic medical record (EMR)

between primary care and subspecialty physicians.

DP – 2006

 

 

TI – Evaluation of a commercial electronic medical record (EMR) by primary care

physicians 5 years after implementation.

DP – 2005

AB – Electronic medical records (EMRs) are gaining increasing prominence in the

delivery of healthcare, although the focus is primarily on deploying EMRs.

Relatively little research has studied the post-implementation of commercial

EMRs. Here we present the results of a web-based survey of all the primary care

clinicians in our university affiliated, tertiary care health system. The survey

evaluated primary care clinician demographics, usage, and ideas for enhancement

of the EpicCare EMR, five year after its initial deployment throughout our

healthcare system.

 

 

 

 

TI – Training experiences of U.S. combined internal medicine and pediatrics residents.

DP – 2006 May

AB – PURPOSE: To investigate the demographics and training experiences of internal

medicine and pediatrics (med-peds) physicians. METHOD: A cross-sectional survey

addressing demographics, training experiences, and career plans of fourth-year

residents graduating from combined internal medicine and pediatrics programs that

were identified in the American Academy of Pediatrics database was initiated in

May 2003. Questionnaires were mailed up to four times to nonresponders through

August 2003. RESULTS: Valid responses were received from 212 of the 340

graduating residents (62% response rate). The majority (186/208 [89%]) reported

that they would choose med-peds training again. Career planning (135/210 [64%]),

office management (173/212 [82%]), and outpatient procedures (155/211 [73%]) were

the only areas where the majority desired more training. Neonatal intensive care

training was the only topic area that the majority of residents (142/212 [67%])

reported could have been carried out in less time. Nearly all residents (183/196

[93%]) planned to care for children and adults. Residents’ self-assessment of 

their preparation was good to excellent for evidence-based medicine (192/210

[91%]), caring for patients with special health care needs (179/209 [86%]), and 

use of information technology (169/208 [81%]). Residents felt equally well

prepared for postgraduate activities in internal medicine and pediatrics primary

care (170/212 [80%] versus 163/211 [77%], p = .305, NS) and internal medicine and

pediatric fellowships (186/207 [90%] versus 181/208 [87%], p = .058, NS). Only

112 of 209 residents (54%) felt their preparation for research was good to

excellent. CONCLUSIONS: The study findings suggest that med-peds residents are

satisfied with their decision to train in med-peds and with their level of

preparation. They feel equally well prepared to care for adults and children, and

well prepared to care for patients that may transition to adulthood with complex

needs, to assess evidence, and to use information technology.

 

 

TI – Combination therapy: medicated urethral system for erection enhances sexual

satisfaction in sildenafil citrate failure following nerve-sparing radical

prostatectomy.

DP – 2005 Nov-Dec

AB – The objective of our study was to assess the effectiveness of combining medicated

urethral system for erection (MUSE) with sildenafil citrate in men unsatisfied

with the sildenafil alone. Baseline and follow-up data from 23 patients (mean

age, 62.5 +/- 5.23 years) unsatisfied with the use of the sildenafil citrate

alone for the treatment of erectile dysfunction following nerve-sparing radical

prostatectomy (mean use, 4 attempts/100-mg dose) was obtained. All patients

started oral sildenafil citrate more than 6 months after radical prostatectomy.

Combination therapy was initiated using 100 mg sildenafil citrate orally 1 hour

prior to intercourse. Patients used combination therapy for a minimum of 4

attempts prior to assessment with the Sexual Health Inventory of Men

(International Index for Erectile Function-5) and visual analog scale to gauge

rigidity (0-100). The effect of therapy on the total International Index for

Erectile Function (IIEF) score and penile rigidity score was assessed. Of the 23

patients, 4 (17%) had no improvement with the addition of medicated urethral

system for erection and discontinued the drug, while 19 (83%) reported

improvement with the penile rigidity and sexual satisfaction. The IIEF scores of

these 19 patients showed significant improvements in each sexual domain, and the

patients reported that erection was sufficient for vaginal penetration 80% of the

time. Rigidity scores on a scale of 0-100 with sildenafil alone averaged 38%

(23-53) for men and 46% (26-67) for their partners. With the addition of MUSE,

scores increased to 76% for men and 62% for their partners. We conclude that the

addition of MUSE to sildenafil improved sexual satisfaction and penile rigidity

in patients unsatisfied with sildenafil alone.

 

 

TI – A Web-based clinical curriculum on the cardiac exam.

DP – 2001 May

 

 

TI – A field-compatible method for interpolating biopotentials.

DP – 1998 Jan-Feb

AB – Mapping of bioelectric potentials over a given surface (e.g., the torso surface,

the scalp) often requires interpolation of potentials into regions of missing

data. Existing interpolation methods introduce significant errors when

interpolating into large regions of high potential gradients, due mostly to their

incompatibility with the properties of the three-dimensional (3D) potential

field. In this paper, an interpolation method, inverse-forward (IF)

interpolation, was developed to be consistent with Laplace’s equation that

governs the 3D field in the volume conductor bounded by the mapped surface. This

method is evaluated in an experimental heart-torso preparation in the context of

electrocardiographic body surface potential mapping. Results demonstrate that IF

interpolation is able to recreate major potential features such as a potential

minimum and high potential gradients within a large region of missing data. Other

commonly used interpolation methods failed to reconstruct major potential

features or preserve high potential gradients. An example of IF interpolation

with patient data is provided to illustrate its applicability in the actual

clinical setting. Application of IF interpolation in the context of noninvasive

reconstruction of epicardial potentials (the “inverse problem”) is also examined.