Pediatric Occupational Therapists' Perspectives on Sleep: A Qualitative Descriptive Study.

IMPORTANCE: Insufficient sleep is common among children seeking occupational therapy services but is rarely a focus of therapy despite sleep's critical impact on health. OBJECTIVE: To examine pediatric occupational therapists' experiences, views, and confidence in addressing sleep concerns in their practice as well as barriers to and supports for doing so. DESIGN: A qualitative descriptive study with thematic analysis of data from 1-hr virtual interviews. Rapport building, multiple-coder analysis, and member checking were used to ensure reliability and validity. SETTING: Interviews were conducted remotely at each participant's preferred time and location. PARTICIPANTS: Pediatric occupational therapists (N = 20) practicing across multiple settings in the United States were recruited through emails directed to their place of work and social media posts. A goal of 20 participants was set a priori with the goal of thematic saturation. OUTCOMES AND MEASURES: A semistructured interview guide. RESULTS: Participants were predominately cisgender (95%), female (85%), and White, non-Hispanic (90%). Overall, they voiced the importance of sleep but reported almost never writing sleep-related goals. Reported barriers that affected the participants' ability to fully address sleep in practice included therapists' lack of confidence and knowledge and low caregiver buy-in. CONCLUSIONS AND RELEVANCE: The findings identify themes on the basis of which actionable steps toward promoting occupational therapists as sleep champions can be developed. Future implications include increasing sleep education opportunities, enhancing awareness of sleep health's impact on goal areas, and facilitating discussions about occupational therapy's role within the medical system and family system in supporting sleep. Plain-Language Summary: This qualitative study identifies what helps and hinders occupational therapists in addressing the sleep health concerns of their clients. We give occupational therapy clinicians and educators key supports to seek out or barriers to address.

Characterizing rest-activity rhythms and sleep for children with and without tactile sensitivities: An observational study.

STUDY OBJECTIVES: This cross-sectional, observational study aimed to characterize and compare movement-based rest-activity rhythms (RARs) and sleep period variables of children with tactile hypersensitivities (SS) and non-sensitive peers (NSS) to expand the understanding of experienced differences in sleep. METHODS: Children (ages 6-10) wore Actigraph GT9X watches for 2 weeks and caregivers completed daily sleep diaries. RARs and sleep period variables (e.g., sleep efficiency, duration, wake after sleep onset) were analyzed and localized means were plotted to visualize average rhythms for each group. Groups were compared using Student's t tests, or non-parametric alternatives, and Hedge's g effect sizes. RESULTS: Fifty-three children and their families participated in this study (nSS = 21 nNSS = 32). The groups had similar RARs and sleep period variables. In both groups, sleep efficiency was low (SESS = 78%, SENSS = 77%) and total sleep time was short (TSTSS = 7 hrs 26 mins, TSTNSS- 7 h, 33 min) compared to national recommendations. Despite these similarities, children with SS took noticeably longer to settle down and fall asleep (53 min) than children with NSS (26 min, p = .075, g = 0.95). CONCLUSION: This study provides preliminary data describing RAR and sleep period variables in children with and without tactile hypersensitivities. While overall RAR and sleep variables were similar between groups, there is evidence that children with SS spend a longer time transitioning to sleep. Evidence is provided that wrist-worn actigraphy is tolerable and acceptable for children with tactile sensitivities. Actigraphy provides important, movement-based data that should be used in tandem with other measures of sleep health for future studies.

Characterizing Sleep Differences in Children With and Without Sensory Sensitivities.

Objectives: Individuals register and react to daily sensory stimuli differently, which influences participation in occupations. Sleep is a foundational nightly occupation that impacts overall health and development in children. Emerging research suggests that certain sensory processing patterns, specifically sensory sensitivities, may have a negative impact on sleep health in children. In this study, we aimed to (i) characterize sleep in children with and without sensory sensitivities and (ii) examine the relationship between sensory processing patterns (using the Sensory Profile-2) and sleep using validated parent- and child-reported questionnaires. We hypothesized that children with sensory sensitivities will exhibit more difficulties with sleep. Methods: We recruited 22 children (ages 6-10) with sensory sensitivities (SS) and 33 children without sensory sensitivities (NSS) to complete validated sleep and sensory processing questionnaires: the Children's Sleep Habits Questionnaire (CSHQ), Sleep Self-Report (SSR), and Sensory Profile-2. Results: Children with SS had significantly more sleep behaviors reported by both parents (p < 0.001, g = 1.11) and children (p < 0.001, g = 1.17) compared to children with NSS. Specifically, children with SS had higher frequencies of sleep anxiety (p = 0.004, g = 0.79), bedtime resistance (p = 0.001, g = 0.83), and sleep onset delay (p = 0.003, g = 0.95). Spearman's ρ correlations indicated significant positive correlations between parent- and child-reported sleep. Children with SS showed a larger association and greater variability between sleep and sensory processing compared to their peers. Significant positive correlations between parent-reported sleep behaviors and sensory sensitive and avoiding patterns were identified for both children with SS and NSS. Child-reported sleep behaviors were most strongly associated with sensitive and avoiding patterns for children with NSS and seeking patterns for children with SS. Conclusion: We present evidence that sleep is impacted for children with SS to a greater extent than children with NSS. We also identified that a child's sensory processing pattern may be an important contributor to sleep problems in children with and without sensory sensitivities. Sleep concerns should be addressed within routine care for children with sensory sensitivities. Future studies will inform specific sleep intervention targets most salient for children with SS and other sensory processing patterns.

EVALUATION OF A TELEHEALTH APPLICATION (SEHHA) USED DURING THE COVID-19 PANDEMIC IN SAUDI ARABIA: PROVIDER EXPERIENCE AND SATISFACTION.

Introduction: COVID-19 has drastically transformed healthcare delivery and forced many to utilize telehealth. This study aimed to comprehensively evaluate the telehealth service "Sehha" used during COVID-19 in Saudi Arabia and assess the provider experience and satisfaction with Sehha. Methods: A questionnaire was distributed by the Ministry of Health (MoH) to 362 physicians using Sehha. The questionnaire items were adapted from previous studies and then tested for content validity and reliability (α = 0.88). Results: The findings showed that most of the physicians improved their experience in telehealth because of COVID-19. The majority of the physicians (67.6 percent) reported being satisfied with Sehha. However, the most commonly perceived challenge by the physicians was difficulty in providing accurate medical assessments. Conclusion: COVID-19 has remarkably uncovered numerous benefits of telehealth. Therefore, telehealth should remain a permanent model of healthcare delivery with consideration of further telehealth development initiatives.

An Exploratory Study Demonstrating the Health Information Management Profession as a STEM Discipline.

It is time to make the case for health information management (HIM) to be included in science, technology, engineering, and math (STEM) education. A careful review of the HIM competencies approved by the American Health Information Management Association (AHIMA) illustrates the role of HIM professionals in informatics, data analytics, and data use. More precisely, the competency subdomains clearly align with content in the STEM disciplines of science, math, and technology, and the individual competencies or tasks in each subdomain solidify the assertion that HIM should be considered part of the STEM disciplines. Evaluation of AHIMA membership data showed that, at the education and work setting levels, AHIMA members are employed in many areas that are common to both HIM and STEM.

A Telehealth Privacy and Security Self-Assessment Questionnaire for Telehealth Providers: Development and Validation.

BACKGROUND: Telehealth is a great approach for providing high quality health care services to people who cannot easily access these services in person. However, because of frequently reported health data breaches, many people may hesitate to use telehealth-based health care services. It is necessary for telehealth care providers to demonstrate that they have taken sufficient actions to protect their patients' data security and privacy. The government provided a HIPAA audit protocol that is highly useful for internal security and privacy auditing on health care systems, however, this protocol includes extensive details that are not always specific to telehealth and therefore is difficult to be used by telehealth practitioners. OBJECTIVE: The goal of this study was to develop and validate a telehealth privacy and security self-assessment questionnaire for telehealth providers. METHODS: In our previous work, we performed a systematic review on the security and privacy protection offered in various telehealth systems. The results from this systematic review and the HIPAA audit protocol were used to guide the development of the self-assessment questionnaire. The draft of the questionnaire was created by the research team and distributed to a group of telehealth providers for evaluating the relevance and clarity of each statement in the draft. The questionnaire was adjusted and finalized according to the collected feedback and face-to-face discussions by the research team. A website was created to distribute the questionnaire and manage the answers from study participants. A psychometric analysis was performed to evaluate the reliability of the questionnaire. RESULTS: There were 84 statements in the draft questionnaire. Five telehealth providers provided their feedback to the statements in this draft. They indicated that a number of these statements were either redundant or beyond the capacity of telehealth care practitioners, who typically do not have formal training in information security. They also pointed out that the wording of some statements needed to be adjusted. The final released version of the questionnaire had 49 statements. In total, 31 telehealth providers across the nation participated in the study by answering all the statements in this questionnaire. The psychometric analysis indicated that the reliability of this questionnaire was high. CONCLUSION: With the availability of this self-assessment questionnaire, telehealth providers can perform a quick self-assessment on their telehealth systems. The assessment results may be used to identify possible vulnerabilities in telehealth systems and practice or demonstrate to patients the sufficient security and privacy protection to patients' data.

Applying a User-Centered Approach to Building a Mobile Personal Health Record App: Development and Usability Study.

BACKGROUND: A personal health record (PHR) system encourages patients to engage with their own health care by giving them the ability to manage and keep track of their own health data. Of the numerous PHR systems available in the market, many are Web-based patient portals and a few are mobile apps. They have mainly been created by hospitals and electronic health record (EHR) vendors. One major limitation of these hospital-created PHR systems is that patients can only view specific health data extracted from their EHR. Patients do not have the freedom to add important personal health data they collect in their daily lives into their PHR. Therefore, there is an information gap between clinical visits. OBJECTIVE: The aim of this study was to develop and evaluate a new mobile PHR app that can be easily used to manage various types of personal health data to fill the information gap. METHODS: A user-centered approach was used to guide the development and evaluation of the new mobile PHR app. There were three steps in this study: needs assessment, app design and development, and conducting a usability study. First, a large-scale questionnaire study was conducted with the general population to gain an understanding of their needs and expectations with regard to a mobile PHR app. A mobile PHR app for personal medical data tracking and management was then created based on the results of the questionnaire study. End users were actively involved in all stages of the app development. Finally, a usability study was performed with participants to evaluate the usability of the mobile PHR app, which involved asking participants to finish a set of tasks and to respond to a usability questionnaire. RESULTS: In the questionnaire study for needs assessment, there were 609 participants in total. The answers from these participants revealed that they wanted to manage various types of personal health data in a mobile PHR app. Participants also reported some features they desired to have in the app. On the basis of the needs assessment findings, a new mobile PHR app (PittPHR) was created with 6 major modules: health records, history, trackers, contacts, appointments, and resources. This app allows users to customize the trackers according to their needs. In the usability study, there were 15 participants. The usability study participants expressed satisfaction with the app and provided comments and suggestions for further development. CONCLUSIONS: This new mobile PHR app provides options for users to manage a wide range of personal health data conveniently in one place. The app fills the information gap between clinical visits. The study results indicated that this new mobile PHR app meets the need of users and that users welcome this app.

eResearch in acute kidney injury: a primer for electronic health record research.

Acute kidney injury (AKI) has a significant impact on patient morbidity and mortality as well as overall health care costs. eResearch, which integrates information technology and information management to optimize research strategies, provides a perfect platform for necessary ongoing AKI research. With the recent adoption of a widely accepted definition of AKI and near-universal use of electronic health records, eResearch is becoming an important tool in AKI research. Conducting eResearch in AKI should ideally be based on a relatively uniform methodology. This article is the first of its kind to describe a methodology for pursuing eResearch specific to AKI and includes an illustrative database example for critically ill patients. We discuss strategies for using serum creatinine and urine output in large databases to identify and stage AKI and ways to interpolate missing values and validate data. Issues specific to the pediatric population include variation in serum creatinine with growth, varied severity of illness scoring systems and medication dosage based on weight. Many of these same strategies used to optimize AKI eResearch can be applicable to real-time AKI alerts with potential integration of additional clinical variables.

Clinical Decision Support for In-Hospital AKI.

AKI carries a significant mortality and morbidity risk. Use of a clinical decision support system (CDSS) might improve outcomes. We conducted a multicenter, sequential period analysis of 528,108 patients without ESRD before admission, from October of 2012 to September of 2015, to determine whether use of a CDSS reduces hospital length of stay and in-hospital mortality for patients with AKI. We compared patients treated 12 months before (181,696) and 24 months after (346,412) implementation of the CDSS. Coprimary outcomes were hospital mortality and length of stay adjusted by demographics and comorbidities. AKI was diagnosed in 64,512 patients (12.2%). Crude mortality rate fell from 10.2% before to 9.4% after CDSS implementation (odds ratio, 0.91; 95% confidence interval [95% CI], 0.86 to 0.96; P=0.001) for patients with AKI but did not change in patients without AKI (from 1.5% to 1.4%). Mean hospital duration decreased from 9.3 to 9.0 days (P<0.001) for patients with AKI, with no change for patients without AKI. In multivariate mixed-effects models, the adjusted odds ratio (95% CI) was 0.76 (0.70 to 0.83) for mortality and 0.66 (0.61 to 0.72) for dialysis (P<0.001). Change in adjusted hospital length of stay was also significant (incidence rate ratio, 0.91; 95% CI, 0.89 to 0.92), decreasing from 7.2 to 6.0 days for patients with AKI. Results were robust to sensitivity analyses and were sustained for the duration of follow-up. Hence, implementation of a CDSS for AKI resulted in a small but sustained decrease in hospital mortality, dialysis use, and length of stay.

A Systematic Review of Research Studies Examining Telehealth Privacy and Security Practices used by Healthcare Providers.

The objective of this systematic review was to systematically review papers in the United States that examine current practices in privacy and security when telehealth technologies are used by healthcare providers. A literature search was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P). PubMed, CINAHL and INSPEC from 2003 - 2016 were searched and returned 25,404 papers (after duplications were removed). Inclusion and exclusion criteria were strictly followed to examine title, abstract, and full text for 21 published papers which reported on privacy and security practices used by healthcare providers using telehealth. Data on confidentiality, integrity, privacy, informed consent, access control, availability, retention, encryption, and authentication were all searched and retrieved from the papers examined. Papers were selected by two independent reviewers, first per inclusion/exclusion criteria and, where there was disagreement, a third reviewer was consulted. The percentage of agreement and Cohen's kappa was 99.04% and 0.7331 respectively. The papers reviewed ranged from 2004 to 2016 and included several types of telehealth specialties. Sixty-seven percent were policy type studies, and 14 percent were survey/interview studies. There were no randomized controlled trials. Based upon the results, we conclude that it is necessary to have more studies with specific information about the use of privacy and security practices when using telehealth technologies as well as studies that examine patient and provider preferences on how data is kept private and secure during and after telehealth sessions.

Privacy and Security in Multi-User Health Kiosks.

Enforcement of the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH) has gotten stricter and penalties have become more severe in response to a significant increase in computer-related information breaches in recent years. With health information said to be worth twice as much as other forms of information on the underground market, making preservation of privacy and security an integral part of health technology development, rather than an afterthought, not only mitigates risks but also helps to ensure HIPAA and HITECH compliance. This paper provides a guide, based on the Office for Civil Rights (OCR) audit protocol, for creating and maintaining an audit checklist for multi-user health kiosks. Implementation of selected audit elements for a multi-user health kiosk designed for use by community-residing older adults illustrates how the guide can be applied.

Use of an electronic health record to identify prevalent and incident cardiovascular disease in type 2 diabetes according to treatment strategy.

BACKGROUND: The increasing use of electronic health records (EHRs) in clinical practice offers the potential to investigate cardiovascular outcomes over time in patients with type 2 diabetes (T2D). OBJECTIVE: To develop a methodology for identifying prevalent and incident cardiovascular disease (CVD) in patients with T2D who are candidates for therapeutic intensification of glucose-lowering therapy. METHODS: Patients with glycated hemoglobin (HbA1c) ≥7% (53 mmol/mol) while receiving 1-2 oral diabetes medications (ODMs) were identified from an EHR (2005-2011) and grouped according to intensification with insulin (INS) (n=372), a different class of ODM (n=833), a glucagon-like peptide receptor 1 agonist (GLP-1RA) (n=59), or no additional therapy (NAT) (n=2017). Baseline prevalence of CVD was defined by documented International Classification of Diseases Ninth Edition (ICD-9) codes for coronary artery disease, cerebrovascular disease, or other CVD with first HbA1c ≥7% (53 mmol/mol). Incident CVD was defined as a new ICD-9 code different from existing codes over 4 years of follow-up. ICD-9 codes were validated by a chart review in a subset of patients. RESULTS: Sensitivity of ICD-9 codes for CVD ranged from 0.83 to 0.89 and specificity from 0.90 to 0.96. Baseline prevalent (INS vs ODM vs GLP-1RA vs NAT: 65% vs 39% vs 54% vs 59%, p<0.001) and incident CVD (Kaplan-Meier estimates: 58%, 31%, 52%, and 54%, p=0.002) were greater in INS group after controlling for differences in baseline HbA1c (9.2±2.0% vs 8.3±1.2% vs 8.2±1.3% vs 7.7±1.1% (77 vs 67 vs 66 vs 61 mmol/mol), p<0.001) and creatinine (1.15±0.96 vs 1.10±0.36 vs 1.01±0.35 vs 1.07±0.45 mg/dL, p=0.001). CONCLUSIONS: An EHR can be an effective method for identifying prevalent and incident CVD in patients with T2D.

Protocol for a Systematic Review of Telehealth Privacy and Security Research to Identify Best Practices.

Healthcare professionals engaged in telehealth are faced with complex US federal regulations (e.g., HIPAA/HITECH) and could benefit from the guidance provided by best practices in Privacy and Security (P&S). This article describes a systematic review protocol to address this need. The protocol described herein uses the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). The PRISMA-P contains 17 items that are considered essential, as well as minimum components to include in systematic reviews. PICOS (participants, interventions, comparisons, outcome(s) and study design of the systematic review) are also relevant to the development of best practices in P&S in telehealth systems. A systematic process can best determine what information should be included and how this information should be retrieved, condensed, analyzed, organized, and disseminated.

Use of an Electronic Medical Record (EMR) to Identify Glycemic Intensification Strategies in Type 2 Diabetes.

BACKGROUND: Current treatment guidelines for type 2 diabetes (T2D) recommend individualized intensification of therapy for glycated hemoglobin (A1C) ≥ 7% in most patients. The purpose of this investigation was to explore the ability of an electronic medical record (EMR) to identify glycemic intensification strategies among T2D patients receiving pharmacologic therapy. METHODS: Patient records between 2005 and 2011 with documentation of A1C and active prescriptions for any diabetes medications were queried to identify potential candidates for intensification based on A1C ≥ 7% while on 1-2 oral diabetes medications (ODM). Patients with follow-up A1C values within 1 year of index A1C were grouped according to intensification with insulin, GLP-1 receptor agonists (GLP-1RA), a new class of ODM, or no intensification. Changes in A1C and continuation of intensification therapy were determined. RESULTS: A total of 4921 patients meeting inclusion criteria were intensified with insulin (n = 416), GLP-1RA (n = 68), ODM (n = 1408), or no additional therapy (n = 3029). Patients receiving insulin had higher baseline (9.3 ± 2.0 vs 8.3 ± 1.2 vs 8.3 ± 1.3 vs 7.6 ± 1.0%, P < .0001) and follow-up A1C (8.1 ± 1.6 vs 7.5 ± 1.2 vs 7.6 ± 1.3 vs 7.2 ± 1.1%, P < .0001) despite experiencing larger absolute A1C reductions (-1.2 ± 2.1 vs -0.8 ± 1.4 vs -0.7 ± 1.4 vs -0.3 ± 1.1%, P < .0001). Patients receiving GLP-1RA were more obese at baseline (BMI: 33.6 ± 7.1 vs 37.7 ± 6.1 vs 33.7 ± 6.8 vs 32.9 ± 7.1 kg/m(2), P < .0001) and follow-up (BMI: 33.9 ± 7.3 vs 36.6 ± 6.1 vs 33.8 ± 7.0 vs 32.4 ± 7.0 kg/m(2), P < .0001) despite experiencing more absolute weight reduction. Insulin was the most and GLP-1RA the least likely therapy to be continued. CONCLUSIONS: An EMR allows identification of prescribing practices and compliance with T2D treatment guidelines. Patients receiving intensification of glycemic medications had baseline A1C >8% suggesting that treatment recommendations are not being followed.

Evaluation of inpatient clinical documentation readiness for ICD-10-CM.

This research study examined the gaps in documentation that occur when coding in ICD-10-CM. More than 4,000 diagnoses from all chapters were coded from 656 electronic documents obtained from a large integrated healthcare facility at the time the study was conducted (2012). After the documents were coded, areas for documentation improvement were identified for chapters that resulted in deficiencies in documentation, and a quick reference guide was developed. The overall absent documentation percentage was 15.4 percent. The 10 chapters with the highest percentage of absent documentation were chapter 7 (Diseases of Eye and Adnexa), with 67.65 percent (p < .001); chapter 8 (Diseases of Ear and Mastoid Process), with 63.64 percent (p < .001); chapter 13 (Diseases of the Musculoskeletal System and Connective Tissue), with 46.05 percent (p < .001); chapter 14 (Diseases of the Genitourinary System), with 40.29 percent (p < .001); chapter 10 (Diseases of Respiratory System), with 35.52 percent (p < .001); chapter 1 (Infectious and Parasitic Diseases), with 32.88 percent (p < .001); chapter 12 (Diseases of the Skin and Subcutaneous Tissue), with 32.35 percent (p < .001); chapter 2 (Neoplasms), with 25.45 percent (p < .001); chapter 4 (Endocrine, Nutritional and Metabolic Diseases), with 14.58 percent (p < .001); and chapter 17 (Congenital Malformations, Deformations, and Chromosomal Abnormalities), with 12.50 percent. We addressed the deficient areas in the quick reference guide developed for clinicians and technology vendors. Having complete and accurate documentation would benefit both the clinician and the patient in providing the highest quality of care.

Elicitation of anti-1918 influenza virus immunity early in life prevents morbidity and lower levels of lung infection by 2009 pandemic H1N1 influenza virus in aged mice.

The Spanish influenza virus pandemic of 1918 was responsible for 40 million to 50 million deaths and is antigenically similar to the swine lineage 2009 pandemic influenza virus. Emergence of the 2009 pandemic from swine into humans has raised the possibility that low levels of cross-protective immunity to past shared epitopes could confer protection. In this study, influenza viruslike particles (VLPs) were engineered to express the hemagglutinin (HA) and genes from the 1918 influenza virus to evaluate the duration of cross-protection to the H1N1 pandemic strain by vaccinating young mice (8 to 12 weeks) and then allowing the animals to age to 20 months. This immunity was long lasting, with homologous receptor-blocking antibodies detected throughout the lifespan of vaccinated mice. Furthermore, the 1918 VLPs fully protected aged mice from 2009 pandemic H1N1 virus challenge 16 months after vaccination. Histopathological assessment showed that aged vaccinated mice had significant protection from alveolar infection but less protection of the bronchial tissue than adult vaccinated mice. Additionally, passive transfer of immune serum from aged vaccinated mice resulted in protection from death but not morbidity. This is the first report describing the lifelong duration of cross-reactive immune responses elicited by a 1918 VLP vaccine in a murine model. Importantly, these lifelong immune responses did not result in decreased total viral replication but did prevent infection of the lower respiratory tract. These findings show that immunity acquired early in life can restrict the anatomical location of influenza viral replication, rather than preventing infection, in the aged.