John R. Lumpkin

Adaptations of avian flu virus are a cause for concern

Members of the National Science Advisory Board for Biosecurity explain its recommendations on the communication of experimental work on H5N1 influenza. We are in the midst of a revolutionary period in the life sciences. Technological capabilities have dramatically expanded, we have a much improved understanding of the complex biology of selected microorganisms, and we have a much improved ability to manipulate microbial genomes. With this has come unprecedented potential for better control of infectious diseases and significant societal benefit. However, there is also a growing risk that the same science will be deliberately misused and that the consequences could be catastrophic. Efforts to describe or define life-sciences research of particular concern have focused on the possibility that knowledge or products derived from such research, or new technologies, could be directly misapplied with a sufficiently broad scope to affect national or global security. Research that might greatly enhance the harm caused by microbial pathogens has been of special concern (1–3). Until now, these efforts have suffered from a lack of specificity and a paucity of concrete examples of “dual use research of concern” (3). Dual use is defined as research that could be used for good or bad purposes. We are now confronted by a potent, real-world example.

Program Requirements for Fellowship Education in the Subspecialty of Clinical Informatics

The Program Requirements for Fellowship Education identify the knowledge and skills that physicians must master through the course of a training program to be certified in the subspecialty of clinical informatics. They also specify accreditation requirements for clinical informatics training programs. The AMIA Board of Directors approved this document in November 2008.

Defining the Medical Subspecialty of Clinical Informatics

As the professional home for biomedical and health informaticians, AMIA is actively working to support high quality relevant professional education and research opportunities. This issue of JAMIA presents two key documents that provide tangible evidence of progress on this front. In this editorial, we describe the context and specific purpose of the two documents, how they were developed, and AMIAs plans to build upon the documents.

Policy: Adaptations of avian flu virus are a cause for concern

Members of the US National Science Advisory Board for Biosecurity explain its recommendations on the communication of experimental work on H5N1 influenza.

From Unequal Treatment to Quality Care

We congratulate the American College of Physicians (ACP) on its position on racial and ethnic disparities (1). The position is comprehensive and consistent with the ACPs mission and can be a model for other specialties and disciplines. The emphasis on enhancing cultural competency is worthy of note because of the role such competency can play in improving outcomes. As noted in the position statement, competency among all health care professionals and support personnel is critical to achieving better outcomes. Not only must practicing physicians be diligent in acquiring cultural competency skills through continuing education, they must ensure that those supporting them in their practices do the same. Translation services are essential to providing culturally competent care because they are key to communication when the clinician and the patient do not speak the same language. Evidence shows that professional translation services are associated with improved patient satisfaction and adherence, as well as improved provider satisfaction (2). For these reasons, clinicians should use professional translators and should consider them to be essential participants in clinical encounters with patients who do not speak the same language. We should not rely on volunteers, who are often family members, friends, or untrained support staff, because this is not consistent with best practices for culturally competent care. Unfortunately, payers do not reimburse for interpretive services, but this shortsightedness does not absolve clinicians of the professional responsibility to provide them. The ACP has taken a strong and commendable position on reimbursement of translation services, especially for Medicare, Medicaid, and the State Childrens Health Insurance Program (SCHIP). To make progress on its agenda for racial and ethnic disparities, the College must place this issue at the top of its policy agenda. Effective communication is a prerequisite for high-quality care. Cultural competency training and interpretive services are good foundations for eliminating racial disparities in health care, but they are just a good beginning. We must also focus our efforts on addressing the subtle forms of bias, such as stereotyping. Many aspects of bias are based on an unconscious cognitive adaptive strategystereotypingthat enables people to make sense of a complex environment. But stereotyping can also negatively affect communication between the patient and physician. As noted in the Institute of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (3), research on stereotyping and practical approaches to eliminating it is an essential part of the comprehensive, long-term set of solutions required to eradicate racial and ethnic disparities. Closing the gap by eliminating the disparities in care between racial and ethnic groups and white populations in the United States is not enough. Unfortunately, even when we close the gap, we will not achieve an acceptable level of care for many conditions. For example, Cooper and Hickson (4) demonstrated disparities between minority and white children enrolled in Medicaid in getting corticosteroid therapy after an emergency department visit. Sadly, the rates of follow-up therapy for all groups fell far short of the ideal. The ACPs leadership and strong commitment to closing the gap and raising the bar are commendable. If the ACP can translate its excellent position statement into a sustained program to change practice, it can make a difference for all patients in this country.

Atención primaria y responsabilidades de salud pública en seis países de Europa y América del Norte: un estudio piloto

BACKGROUND Rapidly occurring changes within the health care systems are creating an opportunity to re-orient the relationships between their different sectors. In order to know the locus of responsibility for various types of preventive activities, we undertook an inquiry on eight areas in six countries from Europe and North America. METHODS An inquiry among experts based on a matrix which arrayed the type of preventive health services against the target population. Eight clinical conditions were identified (childhood immunizations; adult influenza vaccination; mammography screening, tuberculosis screening, hypertension screening. PKU screening, HIV screening, and osteoporosis testing) trying to know their target population and the locus of responsibility for setting of policy, level to contact individuals for testing, follow-up of people with abnormal tests and maintenance of their medical records. RESULTS This pilot study showed very little results coincidence either within the eight surveyed areas or across them. There was no regular pattern for the preventive activities studied among the different countries, neither according to the type of health system, nor to the primary health care orientation of the different systems. CONCLUSIONS There was a limited consensus in the activities studied concerning the best mode of doing public health interventions for personal health services.Fundamento: Los rapidos cambios en los sistemas sanitarios son una oportunidad para reorientar las relaciones entre sus diferentes componentes. Con el objetivo de conocer donde se ubica la responsabilidad para la realizacion de diferentes tipos de actividades preventivas, se realizo una encuesta en ocho areas geograficas de seis paises de Europa y Norteamerica. Metodos: Encuesta entre expertos basada en una matriz que relaciona servicios sanitarios preventivos con la poblacion a la que se dirigen. Se establecieron ocho situaciones clinicas (vacunaciones infantiles y antigripal adultos; y deteccion precoz: de cancer mediante mamografia, de tuberculosis, de Hipertension Arterial, de fenilcetonuria, del virus de la inmunodeficiencia humana, y de osteoporosis), con el fin de conocer en relacion a las mismas la poblacion diana, nivel de establecimiento de las politicas, nivel de contacto con los individuos, seguimiento de los individuos con diagnosticos positivos y registro de sus datos clinicos. Resultados: Este estudio piloto mostro muy escasa coincidencia de los resultados tanto entre las ocho areas encuestadas como en cada una de ellas. No se encontro un patron regular para las actividades de prevencion exploradas entre los diferentes paises, ni en funcion de la tipologia de sus sistemas sanitarios, ni por la orientacion hacia la atencion primaria de los diferentes sistemas. Conclusiones: Existe un escaso consenso en las areas estudiadas en relacion con la mejor forma de realizar las intervenciones de salud publica que conllevan prestacion de atencion sanitaria personal.

The Promise of Electronic Case Reporting

William R. Mac Kenzie, MD, Arthur J. Davidson, MD, MPH, Andrew Wiesenthal, MD, SM, Jeffrey P. Engel, MD, Kathryn Turner, PhD, MPH, Laura Conn, MPH, Scott J. Becker, MS, Sharon Moffatt, MS, Samuel L. Groseclose, DVM, MPH, DACVPM, Jim Jellison, MPH, John Stinn, MA, Nedra Y. Garrett, PhD, Lesliann Helmus, MS, CHTS-CP, Bob Harmon, MD, MPH, Chesley L. Richards, MD, MPH, John R. Lumpkin, MD, MPH, and Michael F. Iademarco, MD, MPH

The importance of establishing a national health security preparedness index.

Natural disasters, infectious disease epidemics, terrorism, and major events like the nuclear incident at Fukushima all pose major potential challenges to public health and security. Events such as the anthrax letters of 2001, Hurricanes Katrina, Irene, and Sandy, severe acute respiratory syndrome (SARS) and West Nile virus outbreaks, and the 2009 H1N1 influenza pandemic have demonstrated that public health, emergency management, and national security efforts are interconnected. These and other events have increased the national resolve and the resources committed to improving the national health security infrastructure. However, as fiscal pressures force federal, state, and local governments to examine spending, there is a growing need to demonstrate both what the investment in public health preparedness has bought and where gaps remain in our nations health security. To address these needs, the Association of State and Territorial Health Officials (ASTHO), through a cooperative agreement with the Centers for Disease Control and Prevention (CDC) Office of Public Health Preparedness and Response (PHPR), is creating an annual measure of health security and preparedness at the national and state levels: the National Health Security Preparedness Index (NHSPI).

High Turnover among State Health Officials/Public Health Directors: Implications for the Public's Health

Context: State health officials (SHOs) serve a critical role as the leaders of state public health systems. Despite their many responsibilities, there is no formal process for preparation to become an SHO, and few requirements influence the selection of an SHO. Furthermore, to date, no studies have examined SHO tenure or their experiences. Objective: This study examines SHO tenure over time and the relationship between SHO tenure and organizational and state attributes. Design: This longitudinal study employed primary data on SHOs and secondary data from the Association of State and Territorial Health Officials on organizational attributes of state public health agencies. Setting: This study examines SHOs within the United States. Participants: SHOs who served in years 1980-2017. Main Outcome Measures: Annual average SHO tenure; average SHO tenure by state. Results: In the 38 years of this study, 508 individuals served as SHOs in the 50 states and the District of Columbia. The average tenure over this period was 4.1 years, with a median tenure of 2.9 years. During the study period, almost 20% of SHOs served terms of 1 year or less. A total of 32 SHOs (32/508 or 6.3%) served for 10 years or longer. Excluding SHOs who served 10 years or longer (n = 32 SHOs who had a collective 478 years of tenure) reduces the average term in office to 3.5 years. The average number of new SHOs per year is 12.3. SHOs appointed by a board of health averaged more than 8 years in office compared with averages just under 4 years for those appointed by governors or secretaries of state agencies. Conclusions: There are notable differences in SHO tenure across states. Future research is needed to further examine SHO tenure, effectiveness, job satisfaction, transitions, and the relationship between SHOs and state health. It may be valuable to expand on opportunities for new SHOs to learn from peers who have moderate to long tenures as well as SHO alumni. Given that average SHO tenure is approximately 4 years and that an SHO could be thrust into the national spotlight at a moments notice, governors may want to consider experience over partisanship as they appoint new SHOs.