Transitioning from One Electronic Health Record to Another: A Systematic Review.

BACKGROUND: Transitioning to a new electronic health record (EHR) presents different challenges than transitions from paper to electronic records. We synthesized the body of peer-reviewed literature on EHR-to-EHR transitions to evaluate the generalizability of published work and identify knowledge gaps where more evidence is needed. METHODS: We conducted a broad search in PubMed through July 2022 and collected all publications from two prior reviews. Peer-reviewed publications reporting on data from an EHR-to-EHR transition were included. We extracted data on study design, setting, sample size, EHR systems involved, dates of transition and data collection, outcomes reported, and key findings. RESULTS: The 40 included publications were grouped into thematic categories for narrative synthesis: clinical care outcomes (n = 15), provider perspectives (n = 11), data migration (n = 8), patient experience (n = 4), and other topics (n = 5). Many studies described single sites that are early adopters of technology with robust research resources, switching from a homegrown system to a commercial system, and emphasized the dynamic effect of transitioning on important clinical care and other outcomes over time. DISCUSSION: The published literature represents a heterogeneous mix of study designs and outcome measures, and while some of the stronger studies in this review used longitudinal approaches to compare outcomes across more sites, the current literature is primarily descriptive and is not designed to offer recommendations that can guide future EHR transitions. Transitioning from one EHR to another constitutes a major organizational change that requires nearly every person in the organization to change how they do their work. Future research should include human factors as well as diverse methodological approaches such as mixed methods and implementation science.

Primary care provider perspectives on virtual and in-person depression management during the COVID-19 pandemic.

INTRODUCTION: During the COVID-19 pandemic, primary care providers (PCPs), nurses, and integrated mental health specialists continued to collaboratively manage depression among patients using both in-person and virtual (i.e., hybrid) modalities. Few studies have characterized how hybrid services are currently delivered within interdisciplinary primary care teams. This study aimed to understand frontline PCPs' perspectives on providing hybrid virtual and in-person depression care during the pandemic. METHOD: From September to November 2020, 12 semistructured individual interviews focused on depression management were conducted with PCPs in two Veterans Health Administration (VA) clinics in Los Angeles, which resumed in-person services while balancing rising COVID-19 cases. Interviews were audio-recorded, transcribed, and coded for depression management patterns. Themes were derived using a team-based constant comparative analytic approach. RESULTS: The pandemic and subsequent expanded use of virtual care necessitated clinic adaptations to depression assessments and procedures. PCPs perceived increased depression and anxiety among patients with existing psychiatric conditions, attributed to social distancing and isolation restrictions. They expressed acceptance of virtual care modalities for patients' depression management. PCPs did not perceive a delay in mental health care delivery in the shift to virtual care but noted the possibility of patients being lost to follow-up. CONCLUSIONS: During the pandemic, there has been heightened PCP concern for patients' emotional well-being and adaptations of clinic processes to meet needs for depression care. While PCPs were optimistic about new virtual care options for depression management, virtual care transfers remained poorly defined and the extent to which patient care experiences and health outcomes have been disrupted remains unknown. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Mental health care integration and primary care patient experience in the Veterans Health Administration.

BACKGROUND: Mental health specialists and care managers facilitate comprehensive care provision within medical homes. Despite implementation challenges, mental health integration is thought to improve patient-centered primary care. OBJECTIVES: To examine the relationship between primary care patient experience and mental health integration. RESEARCH DESIGN: Cross-sectional surveys from 168 primary care clinicians (PCPs) (n = 226) matched with assigned patients' surveys (n = 1734) in one Veterans Health Administration (VA) region, fiscal years 2012-2013. Multilevel regression models examined patient experience and mental health integration, adjusting for patient and PCP characteristics. MEASURES: Patient experience outcomes were (1) experience with PCP and (2) receipt of comprehensive care, such as talked about "stress". Independent variables represented mental health integration- (1) PCP-rated communication with mental health and (2) proportion of clinic patients who saw integrated specialists. RESULTS: 50% and 43% of patients rated their PCPs 10/10 and reported receiving comprehensive care, respectively. Neither patient experience or receipt of comprehensive care was significantly associated with PCP's ratings of communication with mental health, nor with proportion of clinic patients who saw integrated specialists. Among a subsample of patients who rated their mental health as poor/fair, however, we detected an association between proportion of clinic patients who saw integrated specialists and patient experience (odds ratio = 1.05, 95% confidence interval = 1.01-1.09, p = .01). CONCLUSIONS: No association was observed between mental health integration and primary care patients' reported care experiences, but a significant association existed among patients who reported poor/fair mental health. More research is needed to understand patient experiences with regard to care model implementation.

Optogenetic inhibition of neurons by internal light production.

Optogenetics is an extremely powerful tool for selective neuronal activation/inhibition and dissection of neural circuits. However, a limitation of in vivo optogenetics is that an animal must be tethered to an optical fiber for delivery of light. Here, we describe a new method for in vivo, optogenetic inhibition of neural activity using an internal, animal-generated light source based on firefly luciferase. Two adeno-associated viruses encoding luciferase were tested and both produced concentration-dependent light after administration of the substrate, luciferin. Mice were co-infected with halorhodopsin- and luciferase-expressing viruses in the striatum, and luciferin administration significantly reduced Fos activity compared to control animals infected with halorhodopsin only. Recordings of neuronal activity in behaving animals confirmed that firing was greatly reduced after luciferin administration. Finally, amphetamine-induced locomotor activity was reduced in halorhodopsin/luciferase mice pre-injected with luciferin compared to controls. This demonstrates that virally encoded luciferase is able to generate sufficient light to activate halorhodopsin and suppress neural activity and change behavior. This approach could be used to generate inhibition in response to activation of specific molecular pathways.

Medial prefrontal D1 dopamine neurons control food intake.

Although the prefrontal cortex influences motivated behavior, its role in food intake remains unclear. Here, we demonstrate a role for D1-type dopamine receptor-expressing neurons in the medial prefrontal cortex (mPFC) in the regulation of feeding. Food intake increases activity in D1 neurons of the mPFC in mice, and optogenetic photostimulation of D1 neurons increases feeding. Conversely, inhibition of D1 neurons decreases intake. Stimulation-based mapping of prefrontal D1 neuron projections implicates the medial basolateral amygdala (mBLA) as a downstream target of these afferents. mBLA neurons activated by prefrontal D1 stimulation are CaMKII positive and closely juxtaposed to prefrontal D1 axon terminals. Finally, photostimulating these axons in the mBLA is sufficient to increase feeding, recapitulating the effects of mPFC D1 stimulation. These data describe a new circuit for top-down control of food intake.

Gene profiling reveals a role for stress hormones in the molecular and behavioral response to food restriction.

BACKGROUND: Food restriction is known to enhance learning and motivation. The neural mechanisms underlying these responses likely involve alterations in gene expression in brain regions mediating the motivation to feed. METHODS: Analysis of gene expression profiles in male C57BL/6J mice using whole-genome microarrays was completed in the medial prefrontal cortex, nucleus accumbens, ventral tegmental area, and the hypothalamus following a 5-day food restriction. Quantitative polymerase chain reaction was used to validate these findings and determine the time course of expression changes. Plasma levels of the stress hormone corticosterone (CORT) were measured by enzyme-linked immunosorbent assay. Expression changes were measured in adrenalectomized animals that underwent food restriction, as well as in animals receiving daily injections of CORT. Progressive ratio responding for food, a measure of motivated behavior, was assessed after CORT treatment in restricted and fed animals. RESULTS: Brief food restriction results in an upregulation of peripheral stress responsive genes in the mammalian brain. Time-course analysis demonstrated rapid and persistent expression changes in all four brain regions under study. Administration of CORT to nonrestricted animals was sufficient to induce a subset of the genes, and alterations in gene expression after food restriction were dependent on intact adrenal glands. CORT can increase the motivation to work for food only in the restricted state. CONCLUSIONS: These data demonstrate a central role for CORT in mediating both molecular and behavioral responses to food restriction. The stress hormone-induced alterations in gene expression described here may be relevant for both adaptive and pathological responses to stress.

Orexin signaling via the orexin 1 receptor mediates operant responding for food reinforcement.

BACKGROUND: Orexin (hypocretin) signaling is implicated in drug addiction and reward, but its role in feeding and food-motivated behavior remains unclear. METHODS: We investigated orexin's contribution to food-reinforced instrumental responding using an orexin 1 receptor (Ox1r) antagonist, orexin -/- (OKO) and littermate wildtype (WT) mice, and RNAi-mediated knockdown of orexin. C57BL/6J (n = 76) and OKO (n = 39) mice were trained to nose poke for food under a variable ratio schedule of reinforcement. After responding stabilized, a progressive ratio schedule was initiated to evaluate motivation to obtain food reinforcement. RESULTS: Blockade of Ox1r in C57BL/6J mice impaired performance under both the variable ratio and progressive ratio schedules of reinforcement, indicating impaired motivational processes. In contrast, OKO mice initially demonstrated a delay in acquisition but eventually achieved levels of responding similar to those observed in WT animals. Moreover, OKO mice did not differ from WT mice under a progressive ratio schedule, indicating delayed learning processes but no motivational impairments. Considering the differences between pharmacologic blockade of Ox1r and the OKO mice, animals with RNAi mediated knockdown of orexin were then generated and analyzed to eliminate possible developmental effects of missing orexin. Orexin gene knockdown in the lateral hypothalamus in C57BL/6J mice resulted in blunted performance under both the variable ratio and progressive ratio schedules, resembling data obtained following Ox1r antagonism. CONCLUSIONS: The behavior seen in OKO mice likely reflects developmental compensation often seen in mutant animals. These data suggest that activation of the Ox1r is a necessary component of food-reinforced responding, motivation, or both in normal mice.

Systematic comparison of gene expression between murine memory and naive B cells demonstrates that memory B cells have unique signaling capabilities.

Memory B cells play essential roles in the maintenance of long-term immunity and may be important in the pathogenesis of autoimmune disease, but how these cells are distinguished from their naive precursors is poorly understood. To address this, it would be important to understand how gene expression differs between memory and naive B cells to elucidate memory-specific functions. Using model systems that help overcome the lack of murine memory-specific markers and the low frequency of Ag-specific memory and naive cells, we undertook a global comparison of gene expression between memory B cells and their naive precursors. We identified genes with differential expression and confirmed the differential expression of many of these by quantitative RT-PCR and of some of these at the protein level. Our initial analysis revealed differential expression patterns of genes that regulate signaling. Memory B cells have increased expression of genes important in regulating adenosine signaling and in modulating cAMP responses. Furthermore, memory B cells up-regulate receptors that are essential for embryonic stem cell self-renewal. We further demonstrate that one of these, leukemia inhibitory factor receptor, can initiate functional signaling in memory B cells whereas it does not in naive B cells. Thus, memory and naive B cells are intrinsically wired to signal differently from one another and express a functional signaling pathway that is known to maintain stem cells in other lineages.