HIV-1 gp120 mannoses induce immunosuppressive responses from dendritic cells.

The human immunodeficiency virus type 1 (HIV-1) envelope glycoprotein gp120 is a vaccine immunogen that can signal via several cell surface receptors. To investigate whether receptor biology could influence immune responses to gp120, we studied its interaction with human, monocyte-derived dendritic cells (MDDCs) in vitro. Gp120 from the HIV-1 strain JR-FL induced IL-10 expression in MDDCs from 62% of donors, via a mannose C-type lectin receptor(s) (MCLR). Gp120 from the strain LAI was also an IL-10 inducer, but gp120 from the strain KNH1144 was not. The mannose-binding protein cyanovirin-N, the 2G12 mAb to a mannose-dependent gp120 epitope, and MCLR-specific mAbs inhibited IL-10 expression, as did enzymatic removal of gp120 mannose moieties, whereas inhibitors of signaling via CD4, CCR5, or CXCR4 were ineffective. Gp120-stimulated IL-10 production correlated with DC-SIGN expression on the cells, and involved the ERK signaling pathway. Gp120-treated MDDCs also responded poorly to maturation stimuli by up-regulating activation markers inefficiently and stimulating allogeneic T cell proliferation only weakly. These adverse reactions to gp120 were MCLR-dependent but independent of IL-10 production. Since such mechanisms might suppress immune responses to Env-containing vaccines, demannosylation may be a way to improve the immunogenicity of gp120 or gp140 proteins.

US hospital engagement in core domains of interoperability.

OBJECTIVES: To assess US hospital engagement in the 4 core domains of interoperability (find, send, receive, integrate) and whether engaging in these domains is associated with electronic availability of clinical data from outside providers. STUDY DESIGN: Retrospective analysis of survey data. METHODS: Analysis of the American Hospital Association (AHA) Annual Survey of Hospitals and the American Hospital Association (AHA) Annual Survey of Hospitals - IT Supplement datasets for 2014. Respondents included 3307 US hospitals to the AHA Annual Survey - IT Supplement. We created measures of hospital engagement in 4 core domains of interoperability, as well as access to electronic clinical data from outside providers. Regression analysis was to identify hospital characteristics associated with each measure. RESULTS: Twenty-one percent of US hospitals engaged in all 4 interoperability domains, and 25% engaged in none. Hospitals engaged in all 4 domains were more likely to have a "basic" (odds ratio [OR], 3.53; P < .01) or "comprehensive" (OR, 5.04; P < .01) electronic health record (EHR) in comparison to a less than "basic" EHR, participate in a Regional Health Information Organization (OR, 4.29; P < .01), use a single EHR vendor (OR, 2.15; P < .01), and have a third-party health information exchange vendor (OR, 2.32; P < .01). They also differed by non-IT characteristics, such as medical home participation (OR, 1.77; P < .01). Hospitals that find (OR, 5.51; P < .01), receive (OR, 2.56; P < .01), or integrate (OR, 2.53; P < .01) information were more likely to report routine clinical information availability from outside providers. CONCLUSIONS: The one-fifth of US hospitals engaged in key domains of interoperability were more likely to have certain information technology infrastructure and participate in delivery reform. Encouragingly, interoperability engagement was associated with routine clinical information availability. Our results point to the need for ongoing efforts to expand interoperability, with the potential benefit of better information availability for clinicians and better care.

Dispatch from the non-HITECH-incented Health IT world: electronic medication history adoption and utilization.

OBJECTIVE: To document national trends of electronic medication history use in the ambulatory setting and describe the characteristics and predicting factors of providers who regularly use medication history transaction capabilities through their e-prescribing systems. MATERIALS AND METHODS: The study used provider-initiated medication history data requests, electronically sent over an e-prescribing network from all 50 states and the District of Columbia. Data from 138,000 prescribers were evaluated using multivariate analyses from 2007 to 2013. RESULTS: Medication history use showed significant growth, increasing from 8 to 850 million history requests during the study period. Prescribers on the network for <5 years had a lower likelihood of requests than those on the network for 5 or more years. Although descriptive analyses showed that prescribers in rural areas were alongside e-prescribing, and requesting medication histories more often than those in large and small cities, these findings were not significant in multivariate analyses. Providers in orthopedic surgery and internal medicine had a higher likelihood of more requests than family practice prescribers, with 12% and 7% higher likelihood, respectively. DISCUSSION: Early adopters of e-prescribing have remained medication history users and have continually increased their volume of requests for medication histories. CONCLUSION: Despite the fact that the use of medication histories through e-prescribing networks in the ambulatory care setting has not been encouraged through federal incentive programs, there has been substantial growth in the use of medication histories offered through e-prescribing networks.

Electronic Health Record Adoption In US Hospitals: Progress Continues, But Challenges Persist.

Achieving nationwide adoption of electronic health records (EHRs) remains an important policy priority. While EHR adoption has increased steadily since 2010, it is unclear how providers that have not yet adopted will fare now that federal incentives have converted to penalties. We used 2008-14 national data, which includes the most recently available, to examine hospital EHR trends. We found large gains in adoption, with 75 percent of US hospitals now having adopted at least a basic EHR system--up from 59 percent in 2013. However, small and rural hospitals continue to lag behind. Among hospitals without a basic EHR system, the function most often not yet adopted (in 61 percent of hospitals) was physician notes. We also saw large increases in the ability to meet core stage 2 meaningful-use criteria (40.5 percent of hospitals, up from 5.8 percent in 2013); much of this progress resulted from increased ability to meet criteria related to exchange of health information with patients and with other physicians during care transitions. Finally, hospitals most often reported up-front and ongoing costs, physician cooperation, and complexity of meeting meaningful-use criteria as challenges. Our findings suggest that nationwide hospital EHR adoption is in reach but will require attention to small and rural hospitals and strategies to address financial challenges, particularly now that penalties for lack of adoption have begun.

More than half of US hospitals have at least a basic EHR, but stage 2 criteria remain challenging for most.

The national effort to promote the adoption and meaningful use of electronic health records (EHRs) is well under way. However, 2014 marks an important transition: For many hospitals, penalties will be assessed in fiscal year 2015 for failing to meet federal meaningful-use criteria by the end of fiscal year 2014. We used recent data from the American Hospital Association Annual Survey of Hospitals--IT Supplement to assess progress and challenges. EHR adoption among US hospitals continues to rise steeply: 59 percent now have at least a basic EHR. Small and rural hospitals continue to lag behind their better resourced counterparts. Most hospitals are able to meet many of the stage 2 meaningful-use criteria, but only 5.8 percent of hospitals are able to meet them all. Several criteria, including sharing care summaries with other providers and providing patients with online access to their data, will require attention from EHR vendors to ensure that the necessary functions are available and additional effort from many hospitals to make certain that these functionalities are used. Policy makers may want to consider new targeted strategies to ensure that all hospitals move toward meaningful use of EHRs.

Evolving vendor market for HITECH-certified ambulatory EHR products.

BACKGROUND: The ambitious goals of the Health Information Technology for Economic and Clinical Health (HITECH) Act require rapid development and certification of new ambulatory electronic health record (EHR) products. OBJECTIVES: To examine where the vendor market for EHR products stands now and the policy issues emerging from the market's evolution. STUDY DESIGN: Descriptive study with policy analysis. METHODS: We had 3 main sources of information: (1) documents describing this evolving market, which is not well represented in peer-reviewed literature; (2) operational data on certified ambulatory EHR products and their use by Medicareeligible professionals attesting for meaningful use payments from January 2011 to October 2012; and (3) telephone interviews with 10 vendors that account for 57% of the market. RESULTS: Those attesting for Medicare meaningful use payments used ambulatory EHRs from 353 different vendors, although 16 firms accounted for 75% of the market. The Herfindahl-Hirschman Index showed the ambulatory EHR market to be highly competitive, particularly for practices of 50 or fewer professionals. The interviewed vendors and the external analysts agreed that stage 1 requirements set a relatively low bar for market entry, but that likely will change as requirements get more demanding. CONCLUSIONS: The HITECH Act met its initial goals to motivate growth of diverse ambulatory EHR products. A market shakeout may emerge, though current data reveal no signs of it. Policy makers can influence the shape and value of such a shakeout, and the extent of disruption, through their approach to certification and "usability" and "interoperability" strategies and requirements.

Hospital electronic health information exchange grew substantially in 2008-12.

Electronic health information exchange can improve care coordination for patients by enabling more timely and complete sharing of clinical information among providers and hospitals. Approaches to health information exchange have expanded in recent years with the growth in entities such as regional health information organizations (HIOs) and the increased adoption of electronic health record (EHR) systems. However, little is known about the extent of exchange activity in US hospitals. Using national surveys of hospitals, we found that between 2008 and 2012, hospitals' electronic exchange of health information with other providers increased significantly, regardless of provider type, organizational affiliation, or type of clinical information. In 2012 nearly six in ten hospitals actively exchanged electronic health information with providers and hospitals outside their organization, an increase of 41 percent since 2008. EHR adoption and HIO participation were associated with significantly greater hospital exchange activity, but exchanges with providers outside the organization and exchanges of clinical care summaries and medication lists remained limited. New and ongoing policy initiatives and payment reforms may accelerate the electronic exchange of health information by creating new data exchange options, defining standards for interoperability, and creating payment incentives for information sharing across organizational boundaries.

Adoption of electronic health records grows rapidly, but fewer than half of US hospitals had at least a basic system in 2012.

The US health care system is in the midst of an enormous change in the way health care providers and hospitals document, monitor, and share information about health and care delivery. Part of this transition involves a wholesale, but currently uneven, shift from paper-based records to electronic health record (EHR) systems. We used the most recent longitudinal survey of US hospitals to track how they are adopting and using EHR systems. Only 44 percent of hospitals report having and using what we define as at least a basic EHR system. And although 42.2 percent meet all of the federal stage 1 "meaningful-use" criteria, only 5.1 percent could meet the broader set of stage 2 criteria. Large urban hospitals continue to outpace rural and nonteaching hospitals in adopting EHR systems. The increase in adoption overall suggests that the positive and negative financial incentives currently in place across the US health care system are working as intended. However, achieving a nationwide health information technology infrastructure may require efforts targeted at smaller and rural hospitals.