Rita Kukafka

Redesigning electronic health record systems to support public health

Current electronic health record systems are primarily clinical in focus, designed to provide patient-level data and provider-level decision support. Adapting EHR systems to serve public health needs provides the possibility of enormous advances for public health practice and policy. In this review, we evaluate EHR functionality and map it to the three core functions of public health: assessment, policy development, and assurance. In doing so, we identify and discuss important design, implementation, and methodological issues with current systems. For example, in order to support public healths traditional focus on preventive health and socio-behavioral factors, EHR data models would need to be expanded to incorporate environmental, psychosocial, and other non-medical data elements, and workflow would have to be examined to determine the optimal way of collecting these data. We also argue that redesigning EHR systems to support public health offers benefits not only to the public health system but also to consumers, health-care institutions, and individual providers.

Evaluation of the Clinical LOINC (Logical Observation Identifiers, Names, and Codes) Semantic Structure as a Terminology Model for Standardized Assessment Measures

OBJECTIVE The purpose of this study was to test the adequacy of the Clinical LOINC (Logical Observation Identifiers, Names, and Codes) semantic structure as a terminology model for standardized assessment measures. METHODS After extension of the definitions, 1, 096 items from 35 standardized assessment instruments were dissected into the elements of the Clinical LOINC semantic structure. An additional coder dissected at least one randomly selected item from each instrument. When multiple scale types occurred in a single instrument, a second coder dissected one randomly selected item representative of each scale type. RESULTS The results support the adequacy of the Clinical LOINC semantic structure as a terminology model for standardized assessments. Using the revised definitions, the coders were able to dissect into the elements of Clinical LOINC all the standardized assessment items in the sample instruments. Percentage agreement for each element was as follows: component, 100 percent; property, 87.8 percent; timing, 82.9 percent; system/sample, 100 percent; scale, 92.6 percent; and method, 97.6 percent. DISCUSSION This evaluation was an initial step toward the representation of standardized assessment items in a manner that facilitates data sharing and re-use. Further clarification of the definitions, especially those related to time and property, is required to improve inter-rater reliability and to harmonize the representations with similar items already in LOINC.

Peer-to-Peer Communication, Cancer Prevention, and the Internet

Online communication among patients and consumers through support groups, discussion boards, and knowledge resources is becoming more common. In this article, the summary of a workgroup discussion, we discuss key methods through which such web-based peer-to-peer communication may affect health promotion and disease prevention behavior (exchanges of information, emotional and instrumental support, and establishment of group norms and models). We also discuss several theoretical models for studying online peer communication, including social theory, health communication models, and health behavior models. Although online peer communication about health and disease is very common, research evaluating effects on health behaviors, mediators, and outcomes is still relatively sparse. We suggest that future research in this field should include formative evaluation and studies of effects on mediators of behavior change, behaviors, and outcomes. It also will be important to examine spontaneously emerging peer communication efforts to see how they can be integrated with theory-based efforts initiated by researchers.

Effects of Game-Like Interactive Graphics on Risk Perceptions and Decisions

Background. Many patients have difficulty interpreting risks described in statistical terms as percentages. Computer game technology offers the opportunity to experience how often an event occurs, rather than simply read about its frequency. Objective. To assess effects of interactive graphics on risk perceptions and decisions. Design. Electronic questionnaire. Participants and setting. Respondents (n = 165) recruited online or at an urban hospital. Intervention. Health risks were illustrated by either static graphics or interactive game-like graphics. The interactive search graphic was a grid of squares, which, when clicked, revealed stick figures underneath. Respondents had to click until they found a figure affected by the disease. Measurements. Risk feelings, risk estimates, intention to take preventive action. Results. Different graphics did not affect mean risk estimates, risk feelings, or intention. Low-numeracy participants reported significantly higher risk feelings than high-numeracy ones except with the interactive search graphic. Unexpectedly, respondents reported stronger intentions to take preventive action when the intention question followed questions about efficacy and disease severity than when it followed perceived risk questions (65% v. 34%; P < 0.001). When respondents reported risk feelings immediately after using the search graphic, the interaction affected perceived risk (the longer the search to find affected stick figures, the higher the risk feeling: ρ = 0.57; P = 0.009). Limitations. The authors used hypothetical decisions. Conclusions. A game-like graphic that allowed consumers to search for stick figures affected by disease had no main effect on risk perception but reduced differences based on numeracy. In one condition, the game-like graphic increased concern about rare risks. Intentions for preventive action were stronger with a question order that focused first on efficacy and disease severity than with one that focused first on perceived risk.

Policies for patient access to clinical data via PHRs: current state and recommendations

OBJECTIVE Healthcare delivery organizations are increasingly using online personal health records (PHRs) to provide patients with direct access to their clinical information; however, there may be a lack of consistency in the data made available. We aimed to understand the general use and functionality of PHRs and the organizational policies and decision-making structures for making data available to patients. MATERIALS AND METHODS A cross-sectional survey was administered by telephone structured interview to 21 organizations to determine the types of data made available to patients through PHRs and the presence of explicit governance for PHR data release. Organizations were identified based on a review of the literature, PHR experts, and snowball sampling. Organizations that did not provide patients with electronic access to their data via a PHR were excluded. RESULTS Interviews were conducted with 17 organizations for a response rate of 81%. Half of the organizations had explicit governance in the form of a written policy that outlined the data types made available to patients. Overall, 88% of the organizations used a committee structure for the decision-making process and included senior management and information services. All organizations sought input from clinicians. Discussion There was considerable variability in the types of clinical data and the time frame for releasing these data to patients. Variability in data release policies may have implications for PHR use and adoption. CONCLUSIONS Future policy activities, such as requirement specification for the latter stages of Meaningful Use, should be leveraged as an opportunity to encourage standardization of functionality and broad deployment of PHRs.

Reengineering Clinical Research with Informatics

The future success of the translational research spectrum depends on the clinical research enterprises ability to break through the barriers that constrain its productivity. As more basic science discoveries emerge, our ability to effectively translate this knowledge into improved patient care rests squarely on the manner in which we answer clinical questions. Informatics—the science of effective information use—is poised to help advance the conduct of science. However, incorporating informatics into the enterprise comes with its own set of challenges. To harness the benefits of improved information use, it is important to first establish how information flows within research. A thoughtful implementation of informatics—one that factors in social and organizational nuances—will undoubtedly lead to a more efficient and effective clinical research enterprise.

A national agenda for public health informatics.

The American Medical Informatics Association 2001 Spring Congress brought together the public health and informatics communities to develop a national agenda for public health informatics. Discussions on funding and governance; architecture and infrastructure; standards and vocabulary; research, evaluation, and best practices; privacy, confidentiality, and security; and training and workforce resulted in 74 recommendations with two key themes: (1) all stakeholders need to be engaged in coordinated activities related to public health information architecture, standards, confidentiality, best practices, and research and (2) informatics training is needed throughout the public health workforce. Implementation of this consensus agenda will help promote progress in the application of information technology to improve public health.

Effect of Arrangement of Stick Figures on Estimates of Proportion in Risk Graphics

Background. Health risks are sometimes illustrated with stick figures, with a certain proportion colored to indicate they are affected by the disease. Perception of these graphics may be affected by whether the affected stick figures are scattered randomly throughout the group or arranged in a block. Objective. To assess the effects of stick-figure arrangement on first impressions of estimates of proportion, under a 10-s deadline. Design. Questionnaire. Participants and Setting. Respondents recruited online (n = 100) or in waiting rooms at an urban hospital (n = 65). Intervention. Participants were asked to estimate the proportion represented in 6 unlabeled graphics, half randomly arranged and half sequentially arranged. Measurements. Estimated proportions. Results. Although average estimates were fairly good, the variability of estimates was high. Overestimates of random graphics were larger than overestimates of sequential ones, except when the proportion was near 50%; variability was also higher with random graphics. Although the average inaccuracy was modest, it was large enough that more than one quarter of respondents confused 2 graphics depicting proportions that differed by 11 percentage points. Low numeracy and educational level were associated with inaccuracy. Limitations. Participants estimated proportions but did not report perceived risk. Conclusions. Randomly arranged arrays of stick figures should be used with care because viewers’ ability to estimate the proportion in these graphics is so poor that moderate differences between risks may not be visible. In addition, random arrangements may create an initial impression that proportions, especially large ones, are larger than they are.

Health Information Technology and Quality of Health Care: Strategies for Reducing Disparities in Underresourced Settings

Health information technology (health IT) has potential for facilitating quality improvement and reducing quality disparities found in underresourced settings (URSs). With this systematic literature review, complemented by key informant interviews, the authors sought to identify evidence regarding health IT and quality outcomes in URSs. The review included 105 peer-reviewed studies (2004-2009) in all settings. Only 15 studies included URSs, and 8 focused on URSs. Based on literature across settings, most evidence was available for quality impact of order entry, clinical decision support systems, and computerized reminders. Study designs were predominantly quasi-experimental (37%) or descriptive (35%); 90% of the studies focused on the microsystem level of quality improvement, indicating a need for expanding research into patient experience and organizational and environmental levels. Key informants highlighted organizational partnerships and health IT champions and emphasized that for health IT to have an impact on quality, there must be an organizational culture of quality improvement.

Qualitative assessment of the International Classification of Functioning, Disability, and Health with respect to the desiderata for controlled medical vocabularies.

BACKGROUND The International Classification of Functioning, Disability, and Health (ICF), a classification system published in 2001 by the World Health Organization (WHO), provides a common language and framework for describing functional status information (FSI) in health records. METHODS Informed by ongoing research in coding FSI in patient records, this paper qualitatively assesses the ICF framework with respect to the desiderata for controlled medical vocabularies, an enumerated a list of desirable qualities for controlled medical vocabularies proposed by Cimino [J.J. Cimino, Desiderata for controlled medical vocabularies in the twenty-first century, Meth. Inform. Med. 37 (1998) 394-403]. RESULTS The ICF satisfies 5 of the 12 desiderata. Five points were not satisfied and two points could not be evaluated. CONCLUSION The ICF is a rich source of relevant terms, concepts, and relationships, but it was not developed in consideration of requirements for formal terminologies. Therefore, it could serve as a base from which to develop a formal terminology of functioning and disability. This assessment is a key next step in the development of the ICF as a sensitive, universal measure of functional status.