A Model for Multi-Institutional Clinical Data Repository.

Creating a sustainable model for clinical data infrastructure requires the inclusion of key stakeholders, harmonization of their needs and constraints, integration with data governance considerations, conforming to FAIR principles while maintaining data safety and data quality, and maintaining financial health for contributing organizations and partners. This paper reflects on Columbia University's 30+ years of experiences in designing and developing clinical data infrastructure that synergizes both patient care and clinical research missions. We define the desiderata for a sustainable model and make recommendations of best practices to achieve a sustainable model.

Development and validation of prediction models for mechanical ventilation, renal replacement therapy, and readmission in COVID-19 patients.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) patients are at risk for resource-intensive outcomes including mechanical ventilation (MV), renal replacement therapy (RRT), and readmission. Accurate outcome prognostication could facilitate hospital resource allocation. We develop and validate predictive models for each outcome using retrospective electronic health record data for COVID-19 patients treated between March 2 and May 6, 2020. MATERIALS AND METHODS: For each outcome, we trained 3 classes of prediction models using clinical data for a cohort of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2)-positive patients (n = 2256). Cross-validation was used to select the best-performing models per the areas under the receiver-operating characteristic and precision-recall curves. Models were validated using a held-out cohort (n = 855). We measured each model's calibration and evaluated feature importances to interpret model output. RESULTS: The predictive performance for our selected models on the held-out cohort was as follows: area under the receiver-operating characteristic curve-MV 0.743 (95% CI, 0.682-0.812), RRT 0.847 (95% CI, 0.772-0.936), readmission 0.871 (95% CI, 0.830-0.917); area under the precision-recall curve-MV 0.137 (95% CI, 0.047-0.175), RRT 0.325 (95% CI, 0.117-0.497), readmission 0.504 (95% CI, 0.388-0.604). Predictions were well calibrated, and the most important features within each model were consistent with clinical intuition. DISCUSSION: Our models produce performant, well-calibrated, and interpretable predictions for COVID-19 patients at risk for the target outcomes. They demonstrate the potential to accurately estimate outcome prognosis in resource-constrained care sites managing COVID-19 patients. CONCLUSIONS: We develop and validate prognostic models targeting MV, RRT, and readmission for hospitalized COVID-19 patients which produce accurate, interpretable predictions. Additional external validation studies are needed to further verify the generalizability of our results.

An electronic health record (EHR) log analysis shows limited clinician engagement with unsolicited genetic test results.

How clinicians utilize medically actionable genomic information, displayed in the electronic health record (EHR), in medical decision-making remains unknown. Participating sites of the Electronic Medical Records and Genomics (eMERGE) Network have invested resources into EHR integration efforts to enable the display of genetic testing data across heterogeneous EHR systems. To assess clinicians' engagement with unsolicited EHR-integrated genetic test results of eMERGE participants within a large tertiary care academic medical center, we analyzed automatically generated EHR access log data. We found that clinicians viewed only 1% of all the eMERGE genetic test results integrated in the EHR. Using a cluster analysis, we also identified different user traits associated with varying degrees of engagement with the EHR-integrated genomic data. These data contribute important empirical knowledge about clinicians limited and brief engagements with unsolicited EHR-integrated genetic test results of eMERGE participants. Appreciation for user-specific roles provide additional context for why certain users were more or less engaged with the unsolicited results. This study highlights opportunities to use EHR log data as a performance metric to more precisely inform ongoing EHR-integration efforts and decisions about the allocation of informatics resources in genomic research.

Ten principles for data sharing and commercialization.

Digital medical records have enabled us to employ clinical data in many new and innovative ways. However, these advances have brought with them a complex set of demands for healthcare institutions regarding data sharing with topics such as data ownership, the loss of privacy, and the protection of the intellectual property. The lack of clear guidance from government entities often creates conflicting messages about data policy, leaving institutions to develop guidelines themselves. Through discussions with multiple stakeholders at various institutions, we have generated a set of guidelines with 10 key principles to guide the responsible and appropriate use and sharing of clinical data for the purposes of care and discovery. Industry, universities, and healthcare institutions can build upon these guidelines toward creating a responsible, ethical, and practical response to data sharing.

Characterization and clinical course of 1000 patients with COVID-19 in New York: retrospective case series.

Objective: To characterize patients with coronavirus disease 2019 (COVID-19) in a large New York City (NYC) medical center and describe their clinical course across the emergency department (ED), inpatient wards, and intensive care units (ICUs). Design: Retrospective manual medical record review. Setting: NewYork-Presbyterian/Columbia University Irving Medical Center (NYP/CUIMC), a quaternary care academic medical center in NYC. Participants: The first 1000 consecutive patients with laboratory-confirmed COVID-19. Methods: We identified the first 1000 consecutive patients with a positive RT-SARS-CoV-2 PCR test who first presented to the ED or were hospitalized at NYP/CUIMC between March 1 and April 5, 2020. Patient data was manually abstracted from the electronic medical record. Main outcome measures: We describe patient characteristics including demographics, presenting symptoms, comorbidities on presentation, hospital course, time to intubation, complications, mortality, and disposition. Results: Among the first 1000 patients, 150 were ED patients, 614 were admitted without requiring ICU-level care, and 236 were admitted or transferred to the ICU. The most common presenting symptoms were cough (73.2%), fever (72.8%), and dyspnea (63.1%). Hospitalized patients, and ICU patients in particular, most commonly had baseline comorbidities including of hypertension, diabetes, and obesity. ICU patients were older, predominantly male (66.9%), and long lengths of stay (median 23 days; IQR 12 to 32 days); 78.0% developed AKI and 35.2% required dialysis. Notably, for patients who required mechanical ventilation, only 4.4% were first intubated more than 14 days after symptom onset. Time to intubation from symptom onset had a bimodal distribution, with modes at 3-4 and 9 days. As of April 30, 90 patients remained hospitalized and 211 had died in the hospital. Conclusions: Hospitalized patients with COVID-19 illness at this medical center faced significant morbidity and mortality, with high rates of AKI, dialysis, and a bimodal distribution in time to intubation from symptom onset.

Characterization and clinical course of 1000 patients with coronavirus disease 2019 in New York: retrospective case series.

OBJECTIVE: To characterize patients with coronavirus disease 2019 (covid-19) in a large New York City medical center and describe their clinical course across the emergency department, hospital wards, and intensive care units. DESIGN: Retrospective manual medical record review. SETTING: NewYork-Presbyterian/Columbia University Irving Medical Center, a quaternary care academic medical center in New York City. PARTICIPANTS: The first 1000 consecutive patients with a positive result on the reverse transcriptase polymerase chain reaction assay for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) who presented to the emergency department or were admitted to hospital between 1 March and 5 April 2020. Patient data were manually abstracted from electronic medical records. MAIN OUTCOME MEASURES: Characterization of patients, including demographics, presenting symptoms, comorbidities on presentation, hospital course, time to intubation, complications, mortality, and disposition. RESULTS: Of the first 1000 patients, 150 presented to the emergency department, 614 were admitted to hospital (not intensive care units), and 236 were admitted or transferred to intensive care units. The most common presenting symptoms were cough (732/1000), fever (728/1000), and dyspnea (631/1000). Patients in hospital, particularly those treated in intensive care units, often had baseline comorbidities including hypertension, diabetes, and obesity. Patients admitted to intensive care units were older, predominantly male (158/236, 66.9%), and had long lengths of stay (median 23 days, interquartile range 12-32 days); 78.0% (184/236) developed acute kidney injury and 35.2% (83/236) needed dialysis. Only 4.4% (6/136) of patients who required mechanical ventilation were first intubated more than 14 days after symptom onset. Time to intubation from symptom onset had a bimodal distribution, with modes at three to four days, and at nine days. As of 30 April, 90 patients remained in hospital and 211 had died in hospital. CONCLUSIONS: Patients admitted to hospital with covid-19 at this medical center faced major morbidity and mortality, with high rates of acute kidney injury and inpatient dialysis, prolonged intubations, and a bimodal distribution of time to intubation from symptom onset.

Neurological Dashboards and Consultation Turnaround Time at an Academic Medical Center.

BACKGROUND: Neurologists perform a significant amount of consultative work. Aggregative electronic health record (EHR) dashboards may help to reduce consultation turnaround time (TAT) which may reflect time spent interfacing with the EHR. OBJECTIVES: This study was aimed to measure the difference in TAT before and after the implementation of a neurological dashboard. METHODS: We retrospectively studied a neurological dashboard in a read-only, web-based, clinical data review platform at an academic medical center that was separate from our institutional EHR. Using our EHR, we identified all distinct initial neurological consultations at our institution that were completed in the 5 months before, 5 months after, and 12 months after the dashboard go-live in December 2017. Using log data, we determined total dashboard users, unique page hits, patient-chart accesses, and user departments at 5 months after go-live. We calculated TAT as the difference in time between the placement of the consultation order and completion of the consultation note in the EHR. RESULTS: By April 30th in 2018, we identified 269 unique users, 684 dashboard page hits (median hits/user 1.0, interquartile range [IQR] = 1.0), and 510 unique patient-chart accesses. In 5 months before the go-live, 1,434 neurology consultations were completed with a median TAT of 2.0 hours (IQR = 2.5) which was significantly longer than during 5 months after the go-live, with 1,672 neurology consultations completed with a median TAT of 1.8 hours (IQR = 2.2; p = 0.001). Over the following 7 months, 2,160 consultations were completed and median TAT remained unchanged at 1.8 hours (IQR = 2.5). CONCLUSION: At a large academic institution, we found a significant decrease in inpatient consult TAT 5 and 12 months after the implementation of a neurological dashboard. Further study is necessary to investigate the cognitive and operational effects of aggregative dashboards in neurology and to optimize their use.

Emergency department access to a longitudinal medical record.

Our goal is to assess how clinical information from previous visits is used in the emergency department. We used detailed user audit logs to measure access to different data types. We found that clinician-authored notes and laboratory and radiology data were used most often (common data types were used up to 5% to 20% of the time). Data were accessed less than half the time (up to 20% to 50%) even when the user was alerted to the presence of data. Our access rate indicates that health information exchange projects should be conservative in estimating how often shared data will be used and the wide breadth of data accessed indicates that although a clinical summary is likely to be useful, an ideal solution will supply a broad variety of data.

Lanthanum(III) and praseodymium(III) derivatives with dithiocarbamates derived from alpha-amino acids.

Lanthanum(III) and praseodymium(III) complexes with dithiocarbamates have been synthesized by the reactions of lanthanum(III) and praseodymium(III) chloride with barium dithiocarbamate and complexes of type [LnCl(L)H2O]n have been obtained (where Ln=La(III) or Pr(III); L=barium salt of dithiocarbamate derived from glycine, L-leucine, L-valine, DL-alanine). The complexes have been characterized by elemental analysis, molar conductance, electronic absorption and fluorescence, infrared, far infrared, 1H NMR spectral studies. The presence of coordinated water molecule is inferred from thermogravimetric analysis which indicates the loss of one water molecule at 150-170 degrees C. The oscillator strength, Judd-Ofelt intensity parameter, stimulated emission cross-section, etc. have been obtained for different transitions of Pr3+.

Lanthanum(III) and praseodymium(III) complexes with isatin thiosemicarbazones.

Ten new lanthanum(III) and praseodymium(III) complexes of the general formula Na[La(L)2H2O] (Ln=La(III) or Pr(III); LH2=thiosemicarbazones) derived from the condensation of isatin with 4-phenyl thiosemicarbazide, 4-(4-chlorophenyl) thiosemicarbazide, 4-(2-nitrophenyl) thiosemicarbazide, 4-(2-bromophenyl) thiosemicarbazide and 4-(2-methylphenyl) thiosemicarbazide, have been synthesized in methanol in presence of sodium hydroxide. The XRD spectra of the complexes were monitored to verify complex formation. The complexes have also been characterized by elemental analysis, molar conductance, electronic absorption and fluorescence, infrared, far infrared, 1H and 13C NMR spectral studies. Thermal studies of these complexes have been carried out in the temperature range 25-800 degrees C using TG, DTG and DTA techniques. All these complexes decompose gradually with the formation of Ln2O3 as the end product. The Judd-ofelt intensity parameter, oscillator strength, transition probability, stimulated emission cross section for different transitions of Pr3+ for 4-phenyl thiosemicarbazones have been calculated.

Reactions of Cp2MCl2 (M=Ti or Zr) with imine-oxime ligands. Formation of metallacycles.

The reactions of bis(cyclopentadienyl)titanium(IV)/zirconium(IV) dichloride with a series of imine-oxime ligands (LH2), derived by condensing benzil-alpha-monoxime and 2-phenylenediamine, 4-phenylenediamine, 4-methyl-2-phenylenediamine, 2,6-diamino-pyridine, have been studied in anhydrous tetrahydrofuran in the presence of base and metallocycles of the [Cp2M(L)] (M=Ti or Zr) type have been isolated. Tentative structures have been proposed for the products based on elemental analysis, electrical conductance and spectral (electronic, IR and (1)H-NMR) data. Proton NMR spectra indicate that on the NMR time scale there is rapid rotation of the cyclopentadienyl ring around the metal-ring axis at 25 degrees C. Studies were conducted to assess the growth inhibiting potential of the complexes synthesized and the ligands against various bacterial strains.

Nitro and dinitroamino N-oxides of octaazaanthracene as high energy materials.

The present study undertook the design of nitro and dinitroamino compounds from the skeleton of isomeric N-oxides of octaazanaphthalene, using computational methods to predict their degradation and explosive characteristics. The atom equivalent method was employed to evaluate the gas phase heats of formation of the designed species. Condensed phase heats of formation were also determined and found to be in the range of 220-286 kcal mol(-1). Crystal densities of all the designed molecules were calculated and found to be in the range of 1.91-1.98 g cm(-3). Detonation pressure (P) and detonation velocity (D) determined using the Kamlet-Jacobs equation showed that the performance of nitro-substituted compounds was comparable to that of RDX while that of dinitroamino compounds (P ≈ 43.4-43.7 GPa; D ≈ 9.6-9.7 km s(-1)) showed their superiority over HMX (P ≈ 39.3 GPa and D ≈ 9.10 km s(-1)). Impact sensitivity (h 50) of the designed molecules was compared with nitro- and nitramino-based commercial explosives on the basis of the available free space (∆V) per molecule in their crystal lattice estimated using wave function analysis. The study showed that dinitroamino compounds were more sensitive compared to their nitro analogs. Reactivity or chemical stability of the designed molecules were measured in terms of charge distribution, molecular electrostatic potential and frontier molecular orbital energy. The nitro compounds of N-oxides of octaazaanthracene were found to be more stable than their dinitroamino analogs.

Columbia University's Informatics for Diabetes Education and Telemedicine (IDEATel) project: technical implementation.

The Columbia University Informatics for Diabetes Education and Telemedicine IDEATel) project is a four-year demonstration project funded by the Centers for Medicare and Medicaid Services with the overall goal of evaluating the feasibility, acceptability, effectiveness, and cost-effectiveness of telemedicine. The focal point of the intervention is the home telemedicine unit (HTU), which provides four functions: synchronous videoconferencing over standard telephone lines, electronic transmission for fingerstick glucose and blood pressure readings, secure Web-based messaging and clinical data review, and access to Web-based educational materials. The HTU must be usable by elderly patients with no prior computer experience. Providing these functions through the HTU requires tight integration of six components: the HTU itself, case management software, a clinical information system, Web-based educational material, data security, and networking and telecommunications. These six components were integrated through a variety of interfaces, providing a system that works well for patients and providers. With more than 400 HTUs installed, IDEATel has demonstrated the feasibility of large-scale home telemedicine.

Theoretical studies on benzo[1,2,4]triazine-based high-energy materials.

Density functional theory calculations of 13 aminonitro compounds based on the benzo[1,2,4]triazine fused-ring system were performed. The geometries of all 13 species were optimized at the B3LYP/6-31G(d) level of theory. In order to refine the energy values, single-point energy calculations of the species were made at the B3LYP/6-311++G(2df,2p) level. The gas-phase heats of formation of the species considered were calculated using the atom equivalent method. Condensed-phase heats of formation were calculated utilizing the heats of sublimation of the designed molecules, as evaluated during the present study. With the help of the WFA program, crystal densities of the designed compounds were predicted using the geometry of the molecule optimized at the B3PW91/6-31G(d,p) level. The stabilities and impact sensitivities of all of the compounds are discussed in the present paper in terms of the bond dissociation energy (BDE) of the trigger linkage (the longest C-NO2 bond) and the available free space per molecule (∆V) in the unit cell of each compound. A nucleus-independent chemical shift (NICS) study was performed to assess the aromaticities of the designed molecules, and the NICS(1) values determined 1 Å above and below the plane of the ring were found to be -7.9 to -10.5, respectively, for the benzene ring and -10.7 to -11.4, respectively, for the triazine ring in the designed fused-ring molecules, showing that both rings retain their aromaticities when undergoing substitution by nitro groups. Detonation parameters of the species were calculated, and the results suggest that the designed compounds possess comparable values to those of the commercial explosives TNT and RDX. Furthermore, results suggest that the designed compounds may be less sensitive than many nitroaromatic and nitramine explosives. Thus, the results obtained during the present study imply that the designed compounds may be used as safe explosive materials, and could be potential alternatives to TNT and RDX.

Using a pipeline to improve de-identification performance.

Effective de-identification methods are needed to support reuse of electronic health record data for research and other purposes. We investigated using two different text-processing systems in tandem as a strategy for de-identification of clinical notes. We ran 100 outpatient notes through deid.pl, from MIT's PhysioToolkit, followed by MedLEE, and we manually compared the output with original notes to determine the amount of protected health information (PHI) retained. Pipelining resulted in an overall error rate of 2%, with 2 personal names retained in output: one initial and a commonly used English term used in medicine. All retained PHI was transformed into standardized medical concepts, making re-identification less likely. Pipelining using deid.pl improved performance of MedLEE in excluding PHI from output and may be a useful strategy for de-identifying clinical data while providing computer-readable output.

A model for expanded public health reporting in the context of HIPAA.

The advent of electronic medical records and health information exchange raise the possibility of expanding public health reporting to detect a broad range of clinical conditions and of monitoring the health of the public on a broad scale. Expanding public health reporting may require patient anonymity, matching records, re-identifying cases, and recording patient characteristics for localization. The privacy regulations under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) provide several mechanisms for public health surveillance, including using laws and regulations, public health activities, de-identification, research waivers, and limited data sets, and in addition, surveillance may be distributed with aggregate reporting. The appropriateness of these approaches varies with the definition of what data may be included, the requirements of the minimum necessary standard, the accounting of disclosures, and the feasibility of the approach.

An informatics course on applied clinical information systems.

In the ongoing evaluation of our informatics curricula, feedback from alumni indicated a need for a more practically oriented course in clinical systems. This poster presents our experience developing and teaching such a course that seeks to provide students with the principles, concepts and skills needed to plan, implement, and maintain clinical systems.

Synthesis, spectroscopic, and antimicrobial studies of binuclear metallocene (M = Ti, Zr, or Hf) derivatives of bis(mercaptoazoles).

The reactions of (eta(5) - C(5)H(5))(2)MCl(2) (M = Ti, Zr, or Hf) with mercaptoazoles (LH(2)), namely, bis(mercaptotriazoles), bis(mercap- tooxadiazoles), and bis(mercaptothiadiazoles) in 2 : 1 molar ratio, respectively, have been studied in dry tetrahydrofuran in the presence of n-butylamine and the binuclear complexes of the type [{(eta - C(5)H(5))(2) M}(2)(L)] (M = Ti/Zr/Hf) are obtained. Tentative structural conclusions are drawn for the reaction products based upon elemental analysis, electrical conductance, magnetic moment, and spectral data (UV-Vis, IR, (1)H NMR, and (13)C NMR). FAB-mass spectra of few complexes of each series were also carried out to confirm the binuclear structures. Studies were conducted to assess the growth-inhibiting potential of the complexes synthesized, and the ligands against various fungal and bacterial strains.

Does a randall-sundrum scenario create the illusion of a torsion-free universe?

We consider spacetime with torsion in a Randall-Sundrum scenario where torsion, identified with the rank-2 Kalb-Ramond field, exists in the bulk together with gravity. While the interactions of both graviton and torsion in the bulk are controlled by the Planck mass, an additional exponential suppression comes for the torsion zero-mode on the visible brane. This may serve as a natural explanation of why the effect of torsion is so much weaker than that of curvature on the brane. The massive torsion modes, on the other hand, are correlated with the corresponding gravitonic modes and may be detectable in TeV-scale experiments.

Automated identification of shortcuts to patient data for a wireless handheld clinical information system.

Inadequate access to patient information at the point of care has been identified as an impediment to the health care process. To create clinical computing tools that are useful to and used by clinicians, developers of clinical information systems must have accurate models of the users for whom their systems are intended. To create these models, the information needs of clinicians must be understood. While the wireless handheld environment offers many advantages such as the ability to provide mobile access to information, there are a number of challenges. Developing for this environment differs from the laptop and desktop environments due to features such as processing power, screen size, input mechanism, and bandwidth. PalmCIS (Palm-based Clinical Information System) is a clinical application being developed at New York Presbyterian Hospital (NYPH) that provides clinicians with access to patient data via a wireless handheld device. We are using an automated technique to uncover patient-specific information needs of clinicians while using a patient record system. With the results, we can enhance PalmCIS.