A tribute to Karen Greenwood and her contributions to the American Medical Informatics Association.

After 25 years of service to the American Medical Informatics Association (AMIA), Ms Karen Greenwood, the Executive Vice President and Chief Operating Officer, is leaving the organization. In this perspective, we reflect on her accomplishments and her effect on the organization and the field of informatics nationally and globally. We also express our appreciation and gratitude for Ms Greenwood's role at AMIA.

A visual representation of microbiological culture data improves comprehension: a randomized controlled trial.

OBJECTIVE: While the judicious use of antibiotics takes past microbiological culture results into consideration, this data's typical format in the electronic health record (EHR) may be unwieldy when incorporated into clinical decision-making. We hypothesize that a visual representation of sensitivities may aid in their comprehension. MATERIALS AND METHODS: A prospective parallel unblinded randomized controlled trial was undertaken at an academic urban tertiary care center. Providers managing emergency department (ED) patients receiving antibiotics and having previous culture sensitivity testing were included. Providers were randomly selected to use standard EHR functionality or a visual representation of patients' past culture data as they answered questions about previous sensitivities. Concordance between provider responses and past cultures was assessed using the kappa statistic. Providers were surveyed about their decision-making and the usability of the tool using Likert scales. RESULTS: 518 ED encounters were screened from 3/5/2018 to 9/30/18, with providers from 144 visits enrolled and analyzed in the intervention arm and 129 in the control arm. Providers using the visualization tool had a kappa of 0.69 (95% CI: 0.65-0.73) when asked about past culture results while the control group had a kappa of 0.16 (95% CI: 0.12-0.20). Providers using the tool expressed improved understanding of previous cultures and found the tool easy to use (P < .001). Secondary outcomes showed no differences in prescribing practices. CONCLUSION: A visual representation of culture sensitivities improves comprehension when compared to standard text-based representations.

Assessment of Unintentional Duplicate Orders by Emergency Department Clinicians Before and After Implementation of a Visual Aid in the Electronic Health Record Ordering System.

Importance: Electronic health records allow teams of clinicians to simultaneously care for patients, but an unintended consequence is the potential for duplicate orders of tests and medications. Objective: To determine whether a simple visual aid is associated with a reduction in duplicate ordering of tests and medications. Design, Setting, and Participants: This cohort study used an interrupted time series model to analyze 184 694 consecutive patients who visited the emergency department (ED) of an academic hospital with 55 000 ED visits annually. Patient visits occurred 1 year before and after each intervention, as follows: for laboratory orders, from August 13, 2012, to August 13, 2014; for medication orders, from February 3, 2013, to February 3, 2015; and for radiology orders, from December 12, 2013, to December 12, 2015. Data were analyzed from April to September 2019. Exposure: If an order had previously been placed during the ED visit, a red highlight appeared around the checkbox of that order in the computerized provider order entry system. Main Outcomes and Measures: Number of unintentional duplicate laboratory, medication, and radiology orders. Results: A total of 184 694 patients (mean [SD] age, 51.6 [20.8] years; age range, 0-113.0 years; 99 735 [54.0%] women) who visited the ED were analyzed over the 3 overlapping study periods. After deployment of a noninterruptive nudge in electronic health records, there was an associated 49% decrease in the rate of unintentional duplicate orders for laboratory tests (incidence rate ratio, 0.51; 95% CI, 0.45-0.59), from 4485 to 2731 orders, and an associated 40% decrease in unintentional duplicate orders of radiology tests (incidence rate ratio, 0.60; 95% CI, 0.44-0.82), from 956 to 782 orders. There was not a statistically significant change in unintentional duplicate orders of medications (incidence rate ratio, 1.17; 95% CI, 0.52-2.61), which increased from 225 to 287 orders. The nudge eliminated an estimated 17 936 clicks in our electronic health record. Conclusions and Relevance: In this interrupted time series cohort study, passive visual cues that provided just-in-time decision support were associated with reductions in unintentional duplicate orders for laboratory and radiology tests but not in unintentional duplicate medication orders.

Alicanto Online Latin American Maternal Informatics Community of Practice.

Most cases of maternal deaths could be avoided with timely access to quality healthcare, but a key challenge in addressing quality of care in maternal health is the lack of accurate data and analytics. Implementing online communities of practice is a way to resolve this, but in low-and middle-income countries this is particularly challenging. We discuss the design of the Alicanto Online Latin-American Community of Practice that focuses on both outcomes and process indicators.

InfoSAGE: Usage Pattern of a Family-Centric Care Coordination Online Platform.

Globally, there is an expanding elderly population, and families are finding it increasingly challenging to coordinate care for their older family members. This paper reports on the usage patterns of InfoSAGE, an online private social network that has tools for communication and care coordination for elders and their families. This descriptive analysis describes the types of family networks using the platform and types of functionality most used by elders and their family members.

Patient experience with family history tool: analysis of patients' experience sharing their family health history through patient-computer dialogue in a patient portal.

OBJECTIVE: The collection and use of a family health history are important for assessing the patient's risk of disease, but history taking is often impeded by practical barriers in the office. Provision for patient-computer dialogue, linked with the electronic health record, may enable patients to contribute their history while bypassing these barriers. We sought to assess the patient experience using such a tool. MATERIALS AND METHODS: We linked the family history module of a computer-based medical history to the patient portal of a large academic health system. The interview consisted of 39 primary questions with a predetermined high test-retest reliability. Patients' results were structured and summarized, and available within their electronic health record. Patients optionally completed a survey about their experience. We inductively analyzed free-text responses collected between 2014 and 2016. RESULTS: Among 97 781 patient portal users, 9562 patients accessed and 4223 patients completed the family medical history interview. Of these patients, 1451 completed our survey. Main themes that were identified included (1) patient empowerment, (2) anticipated value, (3) validity concerns, (4) privacy concerns, and (5) reflections on patient-computer dialogue. Patients also provided suggestions for the improvement of future family history tools. DISCUSSION: Patients providing their family health information is an example of collaborative electronic work with clinicians and was seen as valuable by those who participated. Concerns related to contextual information and uncertainty need to be addressed. CONCLUSIONS: Patient-computer dialogue to collect family medical history empowered patients and added perceived value and efficiency to the patient experience of care.

An Informatics Framework for Maternal and Child Health (MCH) Monitoring.

Most cases of maternal deaths could be avoided with timely access to quality healthcare, but a key challenge in addressing quality of care in maternal health, is the lack of accurate data. We present a review of the difficulties of collecting and analyzing maternal health data. We propose a comprehensive informatics monitoring framework to track progress on the achievement of the international targets and priorities toward ending preventable maternal mortality and improving maternal and child health, that at the same time builds capacity at institutional and country level to collect indicators and to generate actionable and comparable knowledge that facilitates analysis, research, and evidence-based decision making.

A Usability Evaluation of the InfoSAGE App for Family-Based Medication Management.

The design of a mobile medication manager within a broader family and elder-centric collaboration platform faces challenges of usability and wide applicability. To inform the development and use cases of eldercare apps, we present the preliminary results of a usability study of an iOS and Android app intended for both family members and aging adults for the mobile management of medication lists. Seven participants were recorded during the performance of eight typical use-case scenarios of the medication portion of the InfoSAGE app. Audio and video recordings were analyzed for themes and events. The aim of this paper is to help inform future design choices for eldercare mobile apps.

Information sharing across generations and environments (InfoSAGE): study design and methodology protocol.

BACKGROUND: Longevity creates increasing care needs for healthcare providers and family caregivers. Increasingly, the burden of care falls to one primary caregiver, increasing stress and reducing health outcomes. Additionally, little has been published on adults', over the age of 75, preferences in the development of health information sharing with family members using online platforms. This study aims to assess a novel, Internet based, family-centric communication and collaboration platform created to address the information needs of elders and their informal caregivers in a community setting. METHODS: This study is an internet-based, open prospective cohort study, enrolling dyad pairs of one adult over the age of 75 with one informal caregiver. Dyads will be offered to use the InfoSAGE online platform without prospective assignment. Participants will consent using an online process that enables participation from any location and shares important study and privacy details. The platform will enable the capture of search queries and tracking of functions such as tasks and discussions. Surveys every six months assess health status, health and social needs, and caregiver burden using validated instruments over a two-year period. We will use a mixed methods approach, utilizing qualitative survey data along with website usage analytic data. DISCUSSION: Analysis of the longitudinal usage and survey data will help to examine the patterns of family communication and health information seeking as the central older adult ages. We will use the study data to inform design recommendations relevant to a complex mixture of users, with special consideration to the needs of older adult users and potential physical limitations.

A Systematic Review on Promoting Adherence to Antiretroviral Therapy in HIV-infected Patients Using Mobile Phone Technology.

OBJECTIVE: Adherence to antiretroviral therapy (ART) is paramount to successful long-term suppression of human immunodeficiency virus (HIV). For poorly adherent patients with HIV, barriers to remaining adherent may be overcome by the implementation of targeted interventions delivered via mobile devices. This systematic review is focused specifically on mobile phone technologies to deliver adherence interventions in HIV/acquired immunodeficiency syndrome (AIDS) populations. METHODS: This review (PROSPERO #CRD42017065131) systematically extracted data from published literature from five databases on mobile phone interventions to improve adherence to ART for HIV. The reported studies had been conducted between 2007 and 2017. Risk of bias was assessed using the Cochrane method ranking each criterion as low, high, or unclear risk of bias. RESULTS: Of the 835 articles returned, we identified 26 randomized controlled trials (RCTs), retrospective and prospective cohort trials, or mixed method studies with a comparison group that fit criteria for inclusion. No standard measure of adherence was consistent throughout the examined studies, and assessments by self-report, pill counting, and medication event monitoring system (MEMS) were utilized. The studies reported mixed results, with 17 reporting significant improvements to adherence, 3 reporting improvements without supplying p-values, and 6 reporting no significant change or a reduction in adherence. CONCLUSION: The mixed nature of the results exemplifies the need for more comprehensive approaches and larger scale trials to confirm results observed in limited cohort sizes. To better retain satisfactory adherence within the HIV population, and especially in low-resource settings, we recommend that future interventions incorporate multiple strategies: mobile-based reminders, social support structures, and personalized content.

Rethinking the outpatient medication list: increasing patient activation and education while architecting for centralization and improved medication reconciliation.

Objective: Identify barriers impacting the time consuming and error fraught process of medication reconciliation. Design and implement an electronic medication management system where patient and trusted healthcare proxies can participate in establishing and maintaining an inclusive and up-to-date list of medications. Methods: A patient-facing electronic medication manager was deployed within an existing research project focused on elder care management funded by the AHRQ, InfoSAGE, allowing patients and patients' proxies the ability to build and maintain an accurate and up-to-date medication list. Free and open-source tools available from the U.S. government were used to embed the tenets of centralization, interoperability, data federation, and patient activation into the design. Results: Using patient-centered design and free, open-source tools, we implemented a web and mobile enabled patient-facing medication manager for complex medication management. Conclusions: Patient and caregiver participation are essential to improve medication safety. Our medication manager is an early step towards a patient-facing medication manager that has been designed with data federation and interoperability in mind.

Characteristics of the National Applicant Pool for Clinical Informatics Fellowships (2016-2017).

We conducted a national study to assess the numbers and diversity of applicants for 2016 and 2017 clinical informatics fellowship positions. In each year, we collected data on the number of applications that programs received from candidates who were ultimately successful vs. unsuccessful. In 2017, we also conducted an anonymous applicant survey. Successful candidates applied to an average of 4.2 and 5.5 programs for 2016 and 2017, respectively. In the survey, unsuccessful candidates reported applying to fewer programs. Assuming unsuccessful candidates submitted between 2-5 applications each, the total applicant pool numbered 42-69 for 2016 (competing for 24 positions) and 52-85 for 2017 (competing for 30 positions). Among survey respondents (n=33), 24% were female, 1 was black and none were Hispanic. We conclude that greater efforts are needed to enhance interest in clinical informatics among medical students and residents, particularly among women and members of underrepresented minority groups.

InfoSAGE: Supporting Elders and Families through Online Family Networks.

With an increasingly elderly population, families are finding it increasingly challenging to coordinate care for their older family members. This paper reports on the findings of InfoSAGE, an online private social network that has tools for communication and care coordination for elders and their families. The InfoSAGE system has 257 registered users; 52 of these opted into an in-depth longitudinal study. A descriptive analysis of these early participants, the online family networks, and barriers to participation that were encountered are presented.

InfoSAGE: Use of Online Technologies for Communication and Elder Care.

Aging creates new information and communication needs for families who are helping to coordinate care for frail parents. To identify how information and communication needs evolve with the aging process, we created a living laboratory of families, supported by an online private social network with tools for care coordination. Site registrants are invite to participate in a more in-depth survey-based longitudinal study. In year one, we assessed the feasibility of an online living laboratory. During this first year, 155 individuals registered on InfoSAGE, and 26% opted into the more in-depth longitudinal study. The survey response rate for those in the study was 61%. We present here a descriptive analysis of our early participants and networks, as well as barriers to participation that the study team encountered.

Addressing the Challenges of Aging: How Elders and Their Care Partners Seek Information.

Purpose: Elders in retirement communities face many challenges concerning information and communication. We know little about whether or how online technologies help meet their medical and social needs. The objective of this study was to gain insights into how these elders and their families manage health information and communication. Design and Methods: Qualitative analysis of 10 focus groups with elders and family members. Participants were 30 elders at least 75 years of age residing in 5 senior living communities in and near Boston, MA, and 23 family members. Results: Elders and families turned first to their personal networks when they needed information or help. They stayed informed about elders' health primarily by talking directly with providers. They used online resources infrequently, including portal access to medical records. They wanted online access to medication lists and visit notes, up-to-date information about local services and social activities, and a way to avoid the overwhelming nature of Internet searches. Implications: Elders in senior living communities and their families piece together information primarily from word of mouth communication. In the future, electronic social and collaborative technologies may make information gathering easier.

Accessing Reliable Health Information on the Web: A Review of the HON Approach.

Accessing online health content of high quality and reliability presents challenges. Laypersons cannot easily differentiate trustworthy content from misinformed or manipulated content. This article describes complementary approaches for members of the general public and health professionals to find trustworthy content with as little bias as possible. These include the Khresmoi health search engine (K4E), the Health On the Net Code of Conduct (HONcode) and health trust indicator Web browser extensions.

Improving health care proxy documentation using a web-based interview through a patient portal.

OBJECTIVE: Health care proxy (HCP) documentation is suboptimal. To improve rates of proxy selection and documentation, we sought to develop and evaluate a web-based interview to guide patients in their selection, and to capture their choices in their electronic health record (EHR). METHODS: We developed and implemented a HCP interview within the patient portal of a large academic health system. We analyzed the experience, together with demographic and clinical factors, of the first 200 patients who used the portal to complete the interview. We invited users to comment about their experience and analyzed their comments using established qualitative methods. RESULTS: From January 20, 2015 to March 13, 2015, 139 of the 200 patients who completed the interview submitted their HCP information for their clinician to review in the EHR. These patients had a median age of 57 years (Inter Quartile Range (IQR) 45-67) and most were healthy. The 99 patients who did not previously have HCP information in their EHR were more likely to complete and then submit their information than the 101 patients who previously had a proxy in their health record (odds ratio 2.4, P = .005). Qualitative analysis identified several ways in which the portal-based interview reminded, encouraged, and facilitated patients to complete their HCP. CONCLUSIONS: Patients found our online interview convenient and helpful in facilitating selection and documentation of an HCP. Our study demonstrates that a web-based interview to collect and share a patient's HCP information is both feasible and useful.

Medication Harmony: A Framework to Save Time, Improve Accuracy and Increase Patient Activation.

Incompletely reconciled medication lists contribute to prescribing errors and adverse drug events. Providers expend time and effort at every point of patient contact attempting to curate a best possible medication list, and yet often the list is incomplete or inaccurate. We propose a framework that builds upon the existing infrastructure of a health information exchange (HIE), centralizes data and encourages patient activation. The solution is a constantly accessible, singular, patient-adjudicated medication list that incorporates useful information and features into the list itself. We aim to decrease medication errors across transitions of care, increase awareness of potential drug-drug interactions, improve patient knowledge and self-efficacy regarding medications, decrease polypharmacy, improve prescribing safety and ultimately decrease cost to the health-care system.