OBJECTIVE: Health care proxy (HCP) documentation is suboptimal. To improve rates of proxy selection and documentation, we sought to develop and evaluate a web-based interview to guide patients in their selection, and to capture their choices in their electronic health record (EHR).
METHODS: We developed and implemented a HCP interview within the patient portal of a large academic health system. We analyzed the experience, together with demographic and clinical factors, of the first 200 patients who used the portal to complete the interview. We invited users to comment about their experience and analyzed their comments using established qualitative methods.
RESULTS: From January 20, 2015 to March 13, 2015, 139 of the 200 patients who completed the interview submitted their HCP information for their clinician to review in the EHR. These patients had a median age of 57 years (Inter Quartile Range (IQR) 45-67) and most were healthy. The 99 patients who did not previously have HCP information in their EHR were more likely to complete and then submit their information than the 101 patients who previously had a proxy in their health record (odds ratio 2.4, P = .005). Qualitative analysis identified several ways in which the portal-based interview reminded, encouraged, and facilitated patients to complete their HCP.
CONCLUSIONS: Patients found our online interview convenient and helpful in facilitating selection and documentation of an HCP. Our study demonstrates that a web-based interview to collect and share a patient's HCP information is both feasible and useful.
PURPOSE: OpenNotes is a growing national initiative inviting patients to read clinician progress notes (open notes) through a secure electronic portal. The goals of this study were to (1) identify resident and faculty preceptor attitudes about sharing notes with patients, and (2) assess specific educational needs, policy recommendations, and approaches to facilitate open notes implementation.
METHOD: This was a qualitative study using focus groups with residents and faculty physicians who supervise residents, representing primary care, general surgery, surgical and procedural specialties, and nonprocedural specialties, from Beth Israel Deaconess Medical Center and Geisinger Health System in spring 2013. Data were audio recorded and transcribed verbatim, then coded and organized into themes.
RESULTS: Thirty-six clinicians (24 [66.7%] residents and 12 [33.3%] faculty physicians) participated. Four main themes emerged: (1) implications of full transparency, (2) note audiences and ideology, (3) trust between patients and doctors, and (4) time pressures. Residents and faculty discussed how open notes might yield more engaged patients and better notes but were concerned about the time needed to edit notes and respond to patient inquiries. Residents were uncertain how much detail they should share with patients and were concerned about the potential to harm the patient-doctor relationship. Residents and faculty offered several recommendations for open notes implementation.
CONCLUSIONS: Overall, participants were ambivalent about resident participation in open notes. Residents and faculty identified clinical and educational benefits to open notes but were concerned about potential effects on the patient-doctor relationship, requirements for oversight, and increased workload and burnout.
OBJECTIVES: The Society for Academic Emergency Medicine (SAEM) provides research training grants, but the future productivity of award recipients and nonrecipients is unclear. The study objective was to assess the association of the two SAEM research training mechanisms with scholarly productivity and rates of subsequent funding between nonrecipients and recipients. A secondary goal was to evaluate the productivity metrics for fellows trained at the Institutional Research Training Grant (IRTG) programs.
METHODS: The authors surveyed all 2002 through 2011 Research Training Grant (RTG; n = 64) and Institutional Research Training Grant (IRTG; n = 38) applicants. RTG outcomes were federal funding as a principal investigator (PI) or co-PI using National Institutes of Health RePORTER and scholarly productivity using PubMed. IRTG outcomes were SAEM-approved research fellowships and National Heart, Lung and Blood Institute K12 training awards. Sites applying for or receiving the IRTG multiple times were only counted once. Relative risks (RRs) with 95% confidence intervals (CIs) were calculated.
RESULTS: Over 10 years, nine of 64 (14%) RTG and 10 of 38 (26%) IRTG applications were funded (two sites received multiple awards). Federal funding was obtained by seven of nine (78%) RTG recipients and 22 of 55 (40%) RTG nonrecipients (RR = 1.94, 95% CI = 1.21 to 3.13). All nine (100%, 95% CI = 72% to 100%) of RTG recipients had at least one manuscript, compared to 48 of the 55 (87%, 95% CI = 76% to 95%) nonrecipients. All nine (100%, 95% CI = 72% to 100%) RTG recipients remained in academics versus 44 of 55 (80%, 95% CI = 67% to 90%) nonrecipients. For the IRTG, four of seven awardees (57%, 95% CI = 18% to 90%) versus 0 of the 16 (0%, 95% CI = 0 to 17%) nonrecipients received National Heart, Lung and Blood Institute K12 awards (RR = 19.1, 95% CI = 1.16 to 314.0). Additionally, five of seven (71%, 95% CI = 29% to 96%) institutions became SAEM-approved fellowships compared to one of 16 (6%, 95% CI = 0 to 30%) nonrecipients (RR = 11.4, 95% CI = 1.61 to 80.7).
CONCLUSIONS: SAEM RTG recipients were more likely to obtain federal funding postaward than nonrecipients. IRTG recipients were more likely to develop successful research training programs than nonrecipients.
BACKGROUND: Accurate reporting of patient symptoms is critical for diagnosis and therapeutic monitoring in psychiatry. Smartphones offer an accessible, low-cost means to collect patient symptoms in real time and aid in care.
OBJECTIVE: To investigate adherence among psychiatric outpatients diagnosed with major depressive disorder in utilizing their personal smartphones to run a custom app to monitor Patient Health Questionnaire-9 (PHQ-9) depression symptoms, as well as to examine the correlation of these scores to traditionally administered (paper-and-pencil) PHQ-9 scores.
METHODS: A total of 13 patients with major depressive disorder, referred by their clinicians, received standard outpatient treatment and, in addition, utilized their personal smartphones to run the study app to monitor their symptoms. Subjects downloaded and used the Mindful Moods app on their personal smartphone to complete up to three survey sessions per day, during which a randomized subset of PHQ-9 symptoms of major depressive disorder were assessed on a Likert scale. The study lasted 29 or 30 days without additional follow-up. Outcome measures included adherence, measured by the percentage of completed survey sessions, and estimates of daily PHQ-9 scores collected from the smartphone app, as well as from the traditionally administered PHQ-9.
RESULTS: Overall adherence was 77.78% (903/1161) and varied with time of day. PHQ-9 estimates collected from the app strongly correlated (r=.84) with traditionally administered PHQ-9 scores, but app-collected scores were 3.02 (SD 2.25) points higher on average. More subjects reported suicidal ideation using the app than they did on the traditionally administered PHQ-9.
CONCLUSIONS: Patients with major depressive disorder are able to utilize an app on their personal smartphones to self-assess their symptoms of major depressive disorder with high levels of adherence. These app-collected results correlate with the traditionally administered PHQ-9. Scores recorded from the app may potentially be more sensitive and better able to capture suicidality than the traditional PHQ-9.
OBJECTIVE: Psychiatry residents have numerous online educational resources readily available to them although currently there are no data regarding residents' use and perception of such websites.
METHODS: A survey was offered to 62 residents from all four years of training as well as recent graduates of a single psychiatry residency training program.
RESULTS: Residents reported utilizing online resources on average 68 % of the time, in comparison to 32 % on average for printed materials. Residents reported UpToDate, PubMed, and Wikipedia as the most visited websites and ranked each highly but for different purposes. Thirty-five percent of residents felt that insufficient faculty guidance was a barrier to use of these educational websites.
CONCLUSIONS: Pilot data indicate psychiatry residents use online resources daily for their education in various settings. Resident perceptions of individual website's trustworthiness, ease of use, and sources of clinical decision-making and personal learning suggest potential opportunities for educators to better understand the current use of these resources in residency training. Reported barriers including lack of faculty guidance suggest opportunities for academic psychiatry. Further study is necessary at multiple sites before such results may be generalized.
Smartphones are now ubiquitous and can be harnessed to offer psychiatry a wealth of real-time data regarding patient behavior, self-reported symptoms, and even physiology. The data collected from smartphones meet the three criteria of big data: velocity, volume, and variety. Although these data have tremendous potential, transforming them into clinically valid and useful information requires using new tools and methods as a part of assessment in psychiatry. In this paper, we introduce and explore numerous analytical methods and tools from the computational and statistical sciences that appear readily applicable to psychiatric data collected using smartphones. By matching smartphone data with appropriate statistical methods, psychiatry can better realize the potential of mobile mental health and empower both patients and providers with novel clinical tools.
BACKGROUND: The role and prevention of stigma in mental illness is an area of evolving research.
AIMS: The present study is the first to examine the use and misuse of the word 'schizophrenia' on Twitter.com in comparison with another illness (diabetes) by analyzing Tweets that use the adjective and noun forms of schizophrenia and diabetes.
METHOD: Tweets containing one of four search terms (#schizophrenia, #schizophrenic, #diabetes, #diabetic) were collected over a forty-day time period. After establishing inter-rater reliability, Tweets were rated along three dimensions: medical appropriateness, negativity, and sarcasm. Chi square tests were conducted to examine differences in the distributions of each parameter across illnesses and across each word form (noun versus adjective).
RESULTS: Significant differences were seen between the two illnesses (i.e., among "schizophrenia", "schizophrenic", "diabetes", and "diabetic") along each parameter. Tweets about schizophrenia were more likely to be negative, medically inappropriate, sarcastic, and used non-medically. The adjective ("schizophrenic") was more often negative, medically inappropriate, sarcastic, and used non-medically than the noun "schizophrenia." Schizophrenia tweets were more likely to be negative and sarcastic when used non-medically and in a medically inappropriate manner.
CONCLUSIONS: Our findings confirm the presence of a great deal of misuse of the term schizophrenia on Twitter, and that this misuse is considerably more pronounced by the adjectival use of the illness. These findings have considerable implications for efforts to combat stigma, particularly for youth anti-stigma efforts.
BACKGROUND: There is increasing interest in using mobile technologies such as smartphones for improving the care of patients with schizophrenia. However, less is known about the current clinical evidence for the feasibility and effectiveness of smartphone apps in this population.
OBJECTIVE: To review the published literature of smartphone apps applied for the care of patients with schizophrenia and other psychotic disorders.
METHODS: An electronic database search of Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, Health Technology Assessment Database, Allied and Complementary Medicine, Health and Psychosocial Instruments, PsycINFO, and Embase was conducted on May 24, 2015. All eligible studies were systematically reviewed, and proportional meta-analyses were applied to pooled data on recruitment, retention, and adherence to examine the overall feasibility of smartphone interventions for schizophrenia.
RESULTS: Our search produced 226 results from which 7 eligible articles were identified, reporting on 5 studies of smartphone apps for patients with schizophrenia. All examined feasibility, and one assessed the preliminary efficacy of a smartphone intervention for schizophrenia. Study lengths varied between 6 and 130 days. Overall retention was 92% (95% CI 82-98%). Participants consistently used the smartphone apps on more than 85% of days during the study period, averaging 3.95 interactions per person per day. Furthermore, participants responded to 71.9% of automated prompts (95% CI 65.7-77.8%). Participants reported a range of potential benefits from the various interventions, and user experience was largely positive.
CONCLUSIONS: Although small, the current published literature demonstrates strong evidence for the feasibility of using smartphones to enhance the care of people with schizophrenia. High rates of engagement and satisfaction with a broad range of apps suggest the nascent potential of this mobile technology. However, there remains limited data on the efficacy of such interventions.
Despite increasing recognition of the importance of a strong neuroscience and neuropsychiatry education in the training of psychiatry residents, achieving this competency has proven challenging. In this perspective article, we selectively discuss the current state of these educational efforts and outline how using brain-symptom relationships from a systems-level neural circuit approach in clinical formulations may help residents value, understand, and apply cognitive-affective neuroscience based principles towards the care of psychiatric patients. To demonstrate the utility of this model, we present a case of major depressive disorder and discuss suspected abnormal neural circuits and therapeutic implications. A clinical neural systems-level, symptom-based approach to conceptualize mental illness can complement and expand residents' existing psychiatric knowledge.
As the psychiatric field continues to evolve in a world with nascent mobile technology (Hilty et al., 2014), novel neuroscience and genetic research, and new payment and care models (Fried et al., 2014) it is likely that the psychiatry residents learn today will not match what they will be practicing tomorrow. Residents have the opportunity to help shape that future through conducting research today. While the prospect of research can initially seem daunting to the busy resident, here we examine, from psychiatry residents' perspective, the common pitfalls and rewards of research during residency.
INTRODUCTION: Mobile phones are ubiquitous in society and owned by a majority of psychiatric patients, including those with severe mental illness. Their versatility as a platform can extend mental health services in the areas of communication, self-monitoring, self-management, diagnosis, and treatment. However, the efficacy and reliability of publicly available applications (apps) have yet to be demonstrated. Numerous articles have noted the need for rigorous evaluation of the efficacy and clinical utility of smartphone apps, which are largely unregulated. Professional clinical organizations do not provide guidelines for evaluating mobile apps.
MATERIALS AND METHODS: Guidelines and frameworks are needed to evaluate medical apps. Numerous frameworks and evaluation criteria exist from the engineering and informatics literature, as well as interdisciplinary organizations in similar fields such as telemedicine and healthcare informatics.
RESULTS: We propose criteria for both patients and providers to use in assessing not just smartphone apps, but also wearable devices and smartwatch apps for mental health. Apps can be evaluated by their usefulness, usability, and integration and infrastructure. Apps can be categorized by their usability in one or more stages of a mental health provider's workflow.
CONCLUSIONS: Ultimately, leadership is needed to develop a framework for describing apps, and guidelines are needed for both patients and mental health providers.
Translational Collaboration Platforms connect clinical, genomics, and patient-reported data for the advancement of biomedical research, providing an opportunity to speed up the translating of basic science findings into clinical applications and new medicines. These platforms bring together data from both clinical and research databases and provide opportunities for multi-disciplinary research. Recent years have seen a significant growth of these platforms and some global collaborations research networks have been established using these platforms. In this brief summary of these platforms, we examine the challenges in implementation for global international research collaborations and challenges for the sustainability of research networks.
PURPOSE: Pediatric cancer represents 1% to 4% of all cancers worldwide, with the majority of diagnoses in developing countries where mortality remains much higher than that in high-income countries. We sought to describe differences in ethical decision-making at the end of life among an international sample of pediatric oncologists practicing in countries with a variety of income levels and resource settings.
METHODS: Pediatric oncologists subscribing to an educational international oncology Web site were invited to complete a 38-item web-based survey investigating ethical domains related to end-of-life care: level of care, fiduciary responsibility, decision making, and justice.
RESULTS: Responses were received from 401 physicians in 83 countries, with most respondents practicing in middle-income or high-income countries. Significant differences in attitudes toward ethical issues existed across the national developmental indices.
CONCLUSIONS: Further education on ethical principles is warranted in pediatric oncology, particularly among oncologists practicing in low-income or middle-income countries.
Clinical informatics workforce development is a high priority for medicine. Professional board certification for physicians is an important tool to demonstrating excellence. The recent recognition of clinical informatics as a subspecialty board in the U.S. has generated interest and excitement among the U.S. informatics community. To determine the extent of similar programs in countries around the world, we performed literature searches with relevant keywords and internet searches of websites of informatics societies around the world for mentions or descriptions of certifications and reviewed publicly available sources. The U.S. certification was prominent in the recent published literature. Germany and Belgium have long-standing certifications with South Korea and Sri Lanka considering similar programs. This is the first global view of clinical informatics board certification for physicians. Training and certification for non-physician informatics professionals in allied areas are widespread. Official recognition and certification for physicians and all informatics professionals represents a key component of capacity building and a means of addressing the shortage of a skilled informatics workforce. Wider adoption of certification programs may further attracting talent and accelerate growth of the field.
Left ventricular ejection fraction (LVEF) constitutes an important physiological parameter for the assessment of cardiac function, particularly in the settings of coronary artery disease and heart failure. This study explores the use of routinely and easily acquired variables in the intensive care unit (ICU) to predict severely depressed LVEF following ICU admission. A retrospective study was conducted. We extracted clinical physiological variables derived from ICU monitoring and available within the MIMIC II database and developed a fuzzy model using sequential feature selection and compared it with the conventional logistic regression (LR) model. Maximum predictive performance was observed using easily acquired ICU variables within 6 hours after admission and satisfactory predictive performance was achieved using variables acquired as early as one hour after admission. The fuzzy model is able to predict LVEF ≤ 25% with an AUC of 0.71 ± 0.07, outperforming the LR model, with an AUC of 0.67 ± 0.07. To the best of the authors' knowledge, this is the first study predicting severely impaired LVEF using multivariate analysis of routinely collected data in the ICU. We recommend inclusion of these findings into triaged management plans that balance urgency with resources and clinical status, particularly for reducing the time of echocardiographic examination.
People-centered health care seeks an active role for the patient while empowering all other members of the health care team. By promoting greater patient responsibility and optimal usage, patient-centered health care leads to improved health outcomes, quality of life and optimal value for health care investment. This paper reviews some definitions of people-centered health care and various e-health approaches around the world used to implement this vision. The barriers and enablers to implementation this type of approach are explored. This paper provides a proposed research agenda for future implementations of people-centered e-health.
CONTEXT: The volume of information that must be assimilated to appropriately manage patients with complex or chronic disease can make this task difficult because of the number of data points, their variable temporal availability, and the fact that they may reside in different systems or even institutions. OBJECTIVE .- To outline a framework for building an integrated disease report (IDR) that takes advantage of the capabilities of electronic reporting to create a single, succinct, interpretative report comprising all disease pertinent data.
DESIGN: Disease pertinent data of an IDR include pathology results, laboratory and radiology data, pathologic correlations, risk profiles, and therapeutic implications. We used cancer herein as a representative process for proposing what is, to our knowledge, the first example of standardized guidelines for such a report. The IDR was defined as a modular, dynamic, electronic summary of the most current state of a patient in regard to a particular illness such as lung cancer or diabetes, which includes all information relevant for patient management.
RESULTS: We propose the following 11 core data concepts that an IDR should include: patient identification; patient demographics; disease, diagnosis, and prognosis; tumor board dispositions and decisions; graphic timeline; preresection workup and therapy; resection workup; interpretative comment summarizing pertinent findings; biobanking data; postresection workup; and disease and patient status at follow-up.
CONCLUSIONS: A well-executed IDR should improve patient care and efficiency for health care team members. It would demonstrate the added value of pathology interpretation and likely contribute to a reduction in errors and improved patient safety by decreasing the risk that important data will be overlooked.
IMPORTANCE: Elderly patients often share control of their personal health information and decision making with family and friends when needed. Patient portals can help with information sharing, but concerns about privacy and autonomy of elderly patients remain. Health systems that implement patient portals would benefit from guidance about how best to implement access to portals for caregivers of elderly patients. OBJECTIVE: To identify how patients older than 75 years (hereinafter, elders) and family caregivers of such patients approach sharing of health information, with the hope of applying the results to collaborative patient portals. DESIGN, SETTING, AND PARTICIPANTS: A qualitative study was conducted from October 20, 2013, to February 16, 2014, inviting participants older than 75 years (n = 30) and participants who assist a family member older than 75 years (n = 23) to 1 of 10 discussion groups. Participants were drawn from the Information Sharing Across Generations (InfoSAGE) Living Laboratory, an ongoing study of information needs of elders and families based within an academically affiliated network of senior housing in metropolitan Boston, Massachusetts. Groups were separated into elders and caregivers to allow for more detailed discussion. A professional moderator led groups using a discussion guide. Group discussions were audiotaped, transcribed, and analyzed inductively using immersion/crystallization methods for central themes. MAIN OUTCOMES AND MEASURES: Central themes regarding sharing of health information between elderly patients and family caregivers. RESULTS: Seven lessons emerged from 2 main themes. First, sharing information has consequences: (1) elders and caregivers have different perspectives on what is seen as the "burden" of information, (2) access to medical information by families can have unintended consequences, and (3) elders do not want to feel "spied on" by family. Second, control of information sharing is dynamic: (4) elders wish to retain control of decision making as long as possible, (5) transfer of control occurs gradually depending on elders' health and functional status, (6) control of information sharing and decision making should be fluid to maximize elders' autonomy, and (7) no "one-size-fits-all" approach can satisfy individuals' different preferences. CONCLUSIONS AND RELEVANCE: Information sharing and control are complex issues even under the most well-meaning circumstances. While elders may delegate control and share information with family, they want to retain granular control of their information. When using patient portals, simple proxy access may not adequately address the needs and concerns of aging patients.