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.