Climate-invariant machine learning.

Projecting climate change is a generalization problem: We extrapolate the recent past using physical models across past, present, and future climates. Current climate models require representations of processes that occur at scales smaller than model grid size, which have been the main source of model projection uncertainty. Recent machine learning (ML) algorithms hold promise to improve such process representations but tend to extrapolate poorly to climate regimes that they were not trained on. To get the best of the physical and statistical worlds, we propose a framework, termed "climate-invariant" ML, incorporating knowledge of climate processes into ML algorithms, and show that it can maintain high offline accuracy across a wide range of climate conditions and configurations in three distinct atmospheric models. Our results suggest that explicitly incorporating physical knowledge into data-driven models of Earth system processes can improve their consistency, data efficiency, and generalizability across climate regimes.

Early Intervention Referral Information, Transmission, and Sources-A Survey of State Part C Coordinators and Analysis of Referral Forms.

OBJECTIVE: Early Intervention (EI) referral is a key connector between health care and early childhood systems serving children with developmental risks. This study aimed to describe the US network of EI referrals by answering the following: "What information is sent to EI?", "Who sends it?", and "How is it sent?" METHOD: This study combined an analysis of national document-based and website-based referral forms with a survey of state Part C Coordinators (PCCs). Data on referral forms were systematically collected from state agency websites. PCCs from 52 jurisdictions were surveyed to assess current EI referral practices. Descriptive statistics were used for responses to multiple-choice items; free-text answers were condensed into key study themes. RESULTS: EI referral forms came as e-documents (81%) or websites (35%), and 72% were in English alone. They emphasized family and referral source contact information and reason for the referral. The survey results indicated that health care (45%) sends the most referrals, followed by families (30%). EI agencies received referrals by phone (38%), electronically (23%), e-mail (17%), and fax (17%), and PCCs valued this diversity of methods. Few states received referral data directly from electronic health records (EHRs); however, PCCs hope to eventually receive referrals through websites, mobile devices, and EHRs. CONCLUSION: EI referral data flow is complex, with opportunities for loss of children to follow-up. This study describes how EI referrals occur and provides examples of how communication and access to information may be improved.

Exploiting the power of information in medical education.

The explosion of medical information demands a thorough reconsideration of medical education, including what we teach and assess, how we educate, and whom we educate. Physicians of the future will need to be self-aware, self-directed, resource-effective team players who can synthesize and apply summarized information and communicate clearly. Training in metacognition, data science, informatics, and artificial intelligence is needed. Education programs must shift focus from content delivery to providing students explicit scaffolding for future learning, such as the Master Adaptive Learner model. Additionally, educators should leverage informatics to improve the process of education and foster individualized, precision education. Finally, attributes of the successful physician of the future should inform adjustments in recruitment and admissions processes. This paper explores how member schools of the American Medical Association Accelerating Change in Medical Education Consortium adjusted all aspects of educational programming in acknowledgment of the rapid expansion of information.

Assessing the Transition of Training in Health Systems Science From Undergraduate to Graduate Medical Education.

BACKGROUND: The American Medical Association Accelerating Change in Medical Education (AMA-ACE) consortium proposes that medical schools include a new 3-pillar model incorporating health systems science (HSS) and basic and clinical sciences. One of the goals of AMA-ACE was to support HSS curricular innovation to improve residency preparation. OBJECTIVE: This study evaluates the effectiveness of HSS curricula by using a large dataset to link medical school graduates to internship Milestones through collaboration with the Accreditation Council for Graduate Medical Education (ACGME). METHODS: ACGME subcompetencies related to the schools' HSS curricula were identified for internal medicine, emergency medicine, family medicine, obstetrics and gynecology (OB/GYN), pediatrics, and surgery. Analysis compared Milestone ratings of ACE school graduates to non-ACE graduates at 6 and 12 months using generalized estimating equation models. RESULTS: At 6 months both groups demonstrated similar HSS-related levels of Milestone performance on the selected ACGME competencies. At 1 year, ACE graduates in OB/GYN scored minimally higher on 2 systems-based practice (SBP) subcompetencies compared to non-ACE school graduates: SBP01 (1.96 vs 1.82, 95% CI 0.03-0.24) and SBP02 (1.87 vs 1.79, 95% CI 0.01-0.16). In internal medicine, ACE graduates scored minimally higher on 3 HSS-related subcompetencies: SBP01 (2.19 vs 2.05, 95% CI 0.04-0.26), PBLI01 (2.13 vs 2.01; 95% CI 0.01-0.24), and PBLI04 (2.05 vs 1.93; 95% CI 0.03-0.21). For the other specialties examined, there were no significant differences between groups. CONCLUSIONS: Graduates from schools with training in HSS had similar Milestone ratings for most subcompetencies and very small differences in Milestone ratings for only 5 subcompetencies across 6 specialties at 1 year, compared to graduates from non-ACE schools. These differences are likely not educationally meaningful.

Towards advancing scientific knowledge of climate change impacts on short-duration rainfall extremes.

A large number of recent studies have aimed at understanding short-duration rainfall extremes, due to their impacts on flash floods, landslides and debris flows and potential for these to worsen with global warming. This has been led in a concerted international effort by the INTENSE Crosscutting Project of the GEWEX (Global Energy and Water Exchanges) Hydroclimatology Panel. Here, we summarize the main findings so far and suggest future directions for research, including: the benefits of convection-permitting climate modelling; towards understanding mechanisms of change; the usefulness of temperature-scaling relations; towards detecting and attributing extreme rainfall change; and the need for international coordination and collaboration. Evidence suggests that the intensity of long-duration (1 day+) heavy precipitation increases with climate warming close to the Clausius-Clapeyron (CC) rate (6-7% K-1), although large-scale circulation changes affect this response regionally. However, rare events can scale at higher rates, and localized heavy short-duration (hourly and sub-hourly) intensities can respond more strongly (e.g. 2 × CC instead of CC). Day-to-day scaling of short-duration intensities supports a higher scaling, with mechanisms proposed for this related to local-scale dynamics of convective storms, but its relevance to climate change is not clear. Uncertainty in changes to precipitation extremes remains and is influenced by many factors, including large-scale circulation, convective storm dynamics andstratification. Despite this, recent research has increased confidence in both the detectability and understanding of changes in various aspects of intense short-duration rainfall. To make further progress, the international coordination of datasets, model experiments and evaluations will be required, with consistent and standardized comparison methods and metrics, and recommendations are made for these frameworks. This article is part of a discussion meeting issue 'Intensification of short-duration rainfall extremes and implications for flash flood risks'.

Priorities of Hybrid Clinician-Managers: A Qualitative Study of How Managers Balance Clinical Quality Among Competing Responsibilities.

OBJECTIVE: Oversight of clinical quality is only one of physical therapy managers' multiple responsibilities. With the move to value-based care, organizations need sound management to navigate this evolving reimbursement landscape. Previous research has not explored how competing priorities affect physical therapy managers' oversight of clinical quality. The purpose of this study was to create a preliminary model of the competing priorities, motivations, and responsibilities of managers while overseeing clinical quality. METHODS: This qualitative study used the Rapid Qualitative Inquiry method. A purposive sample of 40 physical therapy managers and corporate leaders was recruited. A research team performed semi-structured interviews and observations in outpatient practices. The team used a grounded theory-based immersion/crystallization analysis approach. Identified themes delineated the competing priorities and workflows these managers use in their administrative duties. RESULTS: Six primary themes were identified that illustrate how managers: (1) balance managerial and professional priorities; (2) are susceptible to stakeholder influences; (3) experience internal conflict; (4) struggle to measure and define quality objectively; (5) are influenced by the culture and structure of their respective organizations; and (6) have professional needs apart from the needs of their clinics. CONCLUSION: Generally, managers' focus on clinical quality is notably less comprehensive than their focus on clinical operations. Additionally, the complex role of hybrid clinician-manager leaves limited time beyond direct patient care for administrative duties. Managers in organizations that hold them accountable to quality-based metrics have more systematic clinical quality oversight processes. IMPACT: This study gives physical therapy organizations a framework of factors that can be influenced to better facilitate managers' effective oversight of clinical quality. Organizations offering support for those managerial responsibilities will be well positioned to thrive in the new fee-for-value care structure.

Metacarpophalangeal Joint Denervation in the Treatment of Dieterich Disease: A Case Report.

Avascular necrosis of the metacarpal head, known as Dieterich disease, is rare. The underlying pathogenesis of the disease is not clearly understood, and there are few cases reported in the literature. Nonoperative treatment with rest and nonsteroidal anti-inflammatory drugs is often successful, but surgical management is sometimes indicated. The case outlined here describes a novel application of the known technique of metacarpophalangeal joint denervation to relieve pain while maintaining joint mechanics and grip strength.

Registered Nurse Strain Detection Using Ambient Data: An Exploratory Study of Underutilized Operational Data Streams in the Hospital Workplace.

BACKGROUND: Registered nurses (RNs) regularly adapt their work to ever-changing situations but routine adaptation transforms into RN strain when service demand exceeds staff capacity and patients are at risk of missed or delayed care. Dynamic monitoring of RN strain could identify when intervention is needed, but comprehensive views of RN work demands are not readily available. Electronic care delivery tools such as nurse call systems produce ambient data that illuminate workplace activity, but little is known about the ability of these data to predict RN strain. OBJECTIVES: The purpose of this study was to assess the utility of ambient workplace data, defined as time-stamped transaction records and log file data produced by non-electronic health record care delivery tools (e.g., nurse call systems, communication devices), as an information channel for automated sensing of RN strain. METHODS: In this exploratory retrospective study, ambient data for a 1-year time period were exported from electronic nurse call, medication dispensing, time and attendance, and staff communication systems. Feature sets were derived from these data for supervised machine learning models that classified work shifts by unplanned overtime. Models for three timeframes -8, 10, and 12 hours-were created to assess each model's ability to predict unplanned overtime at various points across the work shift. RESULTS: Classification accuracy ranged from 57 to 64% across three analysis timeframes. Accuracy was lowest at 10 hours and highest at shift end. Features with the highest importance include minutes spent using a communication device and percent of medications delivered via a syringe. CONCLUSION: Ambient data streams can serve as information channels that contain signals related to unplanned overtime as a proxy indicator of RN strain as early as 8 hours into a work shift. This study represents an initial step toward enhanced detection of RN strain and proactive prevention of missed or delayed patient care.

Stable machine-learning parameterization of subgrid processes for climate modeling at a range of resolutions.

Global climate models represent small-scale processes such as convection using subgrid models known as parameterizations, and these parameterizations contribute substantially to uncertainty in climate projections. Machine learning of new parameterizations from high-resolution model output is a promising approach, but such parameterizations have been prone to issues of instability and climate drift, and their performance for different grid spacings has not yet been investigated. Here we use a random forest to learn a parameterization from coarse-grained output of a three-dimensional high-resolution idealized atmospheric model. The parameterization leads to stable simulations at coarse resolution that replicate the climate of the high-resolution simulation. Retraining for different coarse-graining factors shows the parameterization performs best at smaller horizontal grid spacings. Our results yield insights into parameterization performance across length scales, and they also demonstrate the potential for learning parameterizations from global high-resolution simulations that are now emerging.

Subtle cues: Qualitative elicitation of signs of capacity strain in the hospital workplace.

Through everyday care experiences, nurses develop expertise in recognition of capacity strain in hospital workplaces. Through qualitative interview, experienced nurses identify common activity changes and adaptive work strategies that may signal an imbalance between patient demand and service supply at the bedside. Activity change examples include nurse helping behaviors across patient assignments, increased volume of nurse calls from patient rooms, and decreased presence of staff at the nurses' station. Adaptive work strategies encompass actions taken to recruit resources, move work in time, reduce work demands, or reduce thoroughness of task performance. Nurses' knowledge of perceptible signs of strain provides a foundation for future exploration and development of real-time indicators of capacity strain in hospital-based work systems.

Designing a "Thinking System" to Reduce the Human Burden of Care Delivery.

Cancer patients interact with clinicians who are distributed across locations and organizations. This makes it difficult to coordinate care and adds to the burden of cancer care delivery. Failures in care coordination can harm patients. The rapid growth in the number of cancer survivors and the increasing complexity of cancer care has kindled an interest in new care delivery models. Information technology (IT) is an important component of care delivery. While IT can potentially enhance collaborative work among people distributed across locations, organizations and time, the current design and implementation of health IT adds to the human burden and often makes it a part of the problem instead of the solution. A new paradigm is needed, therefore, to drive innovations that reframe health IT as an enabler (and a component) of a "thinking system," in which patients, caregivers, and clinicians, even when distributed across locations and time, can collaborate to deliver high-quality care while decreasing the burden of care delivery. In a thinking system, the design of collaborative work in health care delivery is based on an understanding of complex interplay among social and technological components. We propose six core design properties for a thinking system: task coordination; information curation; creative and flexible organizing; establishing a common ground; continuity and connection; and co-production. A thinking system is needed to address the complexity of coordination, meet the rising expectation of personalized care, relieve the human burden in care delivery, and to deliver the best quality care that modern science can provide.

Changing available energy for extratropical cyclones and associated convection in Northern Hemisphere summer.

The circulation of the Northern Hemisphere extratropical troposphere has changed over recent decades, with marked decreases in extratropical cyclone activity and eddy kinetic energy (EKE) in summer and increases in the fraction of precipitation that is convective in all seasons. Decreasing EKE in summer is partly explained by a weakening meridional temperature gradient, but changes in vertical temperature gradients and increasing moisture also affect the mean available potential energy (MAPE), which is the energetic reservoir from which extratropical cyclones draw. Furthermore, the relation of changes in mean thermal structure and moisture to changes in convection associated with extratropical cyclones is poorly understood. Here we calculate trends in MAPE for the Northern extratropics in summer over the years 1979-2017, and we decompose MAPE into both convective and nonconvective components. Nonconvective MAPE decreased over this period, consistent with decreases in EKE and extratropical cyclone activity, but convective MAPE increased, implying an increase in the energy available to convection. Calculations with idealized atmospheres indicate that nonconvective and convective MAPE both increase with increasing mean surface temperature and decrease with decreasing meridional surface temperature gradient, but convective MAPE is relatively more sensitive to the increase in mean surface temperature. These results connect changes in the atmospheric mean state with changes in both large-scale and convective circulations, and they suggest that extratropical cyclones can weaken even as their associated convection becomes more energetic.

Trends in continental temperature and humidity directly linked to ocean warming.

In recent decades, the land surface has warmed substantially more than the ocean surface, and relative humidity has fallen over land. Amplified warming and declining relative humidity over land are also dominant features of future climate projections, with implications for climate-change impacts. An emerging body of research has shown how constraints from atmospheric dynamics and moisture budgets are important for projected future land-ocean contrasts, but these ideas have not been used to investigate temperature and humidity records over recent decades. Here we show how both the temperature and humidity changes observed over land between 1979 and 2016 are linked to warming over neighboring oceans. A simple analytical theory, based on atmospheric dynamics and moisture transport, predicts equal changes in moist static energy over land and ocean and equal fractional changes in specific humidity over land and ocean. The theory is shown to be consistent with the observed trends in land temperature and humidity given the warming over ocean. Amplified land warming is needed for the increase in moist static energy over drier land to match that over ocean, and land relative humidity decreases because land specific humidity is linked via moisture transport to the weaker warming over ocean. However, there is considerable variability about the best-fit trend in land relative humidity that requires further investigation and which may be related to factors such as changes in atmospheric circulations and land-surface properties.

Empiric Antibiotic Prescribing Decisions Among Medical Residents: The Role of the Antibiogram.

OBJECTIVETo assess general medical residents' familiarity with antibiograms using a self-administered surveyDESIGNCross-sectional, single-center surveyPARTICIPANTSResidents in internal medicine, family medicine, and pediatrics at an academic medical centerMETHODSParticipants were administered an anonymous survey at our institution during regularly scheduled educational conferences between January and May 2012. Questions collected data regarding demographics, professional training; further open-ended questions assessed knowledge and use of antibiograms regarding possible pathogens, antibiotic regimens, and prescribing resources for 2 clinical vignettes; a series of directed, closed-ended questions followed. Bivariate analyses to compare responses between residency programs were performed.RESULTSOf 122 surveys distributed, 106 residents (87%) responded; internal medicine residents accounted for 69% of responses. More than 20% of residents could not accurately identify pathogens to target with empiric therapy or select therapy with an appropriate spectrum of activity in response to the clinical vignettes; correct identification of potential pathogens was not associated with selecting appropriate therapy. Only 12% of respondents identified antibiograms as a resource when prescribing empiric antibiotic therapy for scenarios in the vignettes, with most selecting the UpToDate online clinical decision support resource or The Sanford Guide. When directly questioned, 89% reported awareness of institutional antibiograms, but only 70% felt comfortable using them and only 44% knew how to access them.CONCLUSIONSWhen selecting empiric antibiotics, many residents are not comfortable using antibiograms as part of treatment decisions. Efforts to improve antibiotic use may benefit from residents being given additional education on both infectious diseases pharmacotherapy and antibiogram utilization.Infect Control Hosp Epidemiol 2018;39:578-583.

Clinical decisions support malfunctions in a commercial electronic health record.

OBJECTIVES: Determine if clinical decision support (CDS) malfunctions occur in a commercial electronic health record (EHR) system, characterize their pathways and describe methods of detection. METHODS: We retrospectively examined the firing rate for 226 alert type CDS rules for detection of anomalies using both expert visualization and statistical process control (SPC) methods over a five year period. Candidate anomalies were investigated and validated. RESULTS: Twenty-one candidate CDS anomalies were identified from 8,300 alert-months. Of these candidate anomalies, four were confirmed as CDS malfunctions, eight as false-positives, and nine could not be classified. The four CDS malfunctions were a result of errors in knowledge management: 1) inadvertent addition and removal of a medication code to the electronic formulary list; 2) a seasonal alert which was not activated; 3) a change in the base data structures; and 4) direct editing of an alert related to its medications. 154 CDS rules (68%) were amenable to SPC methods and the test characteristics were calculated as a sensitivity of 95%, positive predictive value of 29% and F-measure 0.44. DISCUSSION: CDS malfunctions were found to occur in our EHR. All of the pathways for these malfunctions can be described as knowledge management errors. Expert visualization is a robust method of detection, but is resource intensive. SPC-based methods, when applicable, perform reasonably well retrospectively. CONCLUSION: CDS anomalies were found to occur in a commercial EHR and visual detection along with SPC analysis represents promising methods of malfunction detection.

ACC/AHA Special Report: Clinical Practice Guideline Implementation Strategies: A Summary of Systematic Reviews by the NHLBI Implementation Science Work Group: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

BACKGROUND: In 2008, the National Heart, Lung, and Blood Institute convened an Implementation Science Work Group to assess evidence-based strategies for effectively implementing clinical practice guidelines. This was part of a larger effort to update existing clinical practice guidelines on cholesterol, blood pressure, and overweight/obesity. OBJECTIVES: Review evidence from the published implementation science literature and identify effective or promising strategies to enhance the adoption and implementation of clinical practice guidelines. METHODS: This systematic review was conducted on 4 critical questions, each focusing on the adoption and effectiveness of 4 intervention strategies: (1) reminders, (2) educational outreach visits, (3) audit and feedback, and (4) provider incentives. A scoping review of the Rx for Change database of systematic reviews was used to identify promising guideline implementation interventions aimed at providers. Inclusion and exclusion criteria were developed a priori for each question, and the published literature was initially searched up to 2012, and then updated with a supplemental search to 2015. Two independent reviewers screened the returned citations to identify relevant reviews and rated the quality of each included review. RESULTS: Audit and feedback and educational outreach visits were generally effective in improving both process of care (15 of 21 reviews and 12 of 13 reviews, respectively) and clinical outcomes (7 of 12 reviews and 3 of 5 reviews, respectively). Provider incentives showed mixed effectiveness for improving both process of care (3 of 4 reviews) and clinical outcomes (3 reviews equally distributed between generally effective, mixed, and generally ineffective). Reminders showed mixed effectiveness for improving process of care outcomes (27 reviews with 11 mixed and 3 generally ineffective results) and were generally ineffective for clinical outcomes (18 reviews with 6 mixed and 9 generally ineffective results). Educational outreach visits (2 of 2 reviews), reminders (3 of 4 reviews), and provider incentives (1 of 1 review) were generally effective for cost reduction. Educational outreach visits (1 of 1 review) and provider incentives (1 of 1 review) were also generally effective for cost-effectiveness outcomes. Barriers to clinician adoption or adherence to guidelines included time constraints (8 reviews/overviews); limited staffing resources (2 overviews); timing (5 reviews/overviews); clinician skepticism (5 reviews/overviews); clinician knowledge of guidelines (4 reviews/overviews); and higher age of the clinician (1 overview). Facilitating factors included guideline characteristics such as format, resources, and end-user involvement (6 reviews/overviews); involving stakeholders (5 reviews/overviews); leadership support (5 reviews/overviews); scope of implementation (5 reviews/overviews); organizational culture such as multidisciplinary teams and low-baseline adherence (9 reviews/overviews); and electronic guidelines systems (3 reviews). CONCLUSION: The strategies of audit and feedback and educational outreach visits were generally effective in improving both process of care and clinical outcomes. Reminders and provider incentives showed mixed effectiveness, or were generally ineffective. No general conclusion could be reached about cost effectiveness, because of limitations in the evidence. Important gaps exist in the evidence on effectiveness of implementation interventions, especially regarding clinical outcomes, cost effectiveness and contextual issues affecting successful implementation.

ACC/AHA Special Report: Clinical Practice Guideline Implementation Strategies: A Summary of Systematic Reviews by the NHLBI Implementation Science Work Group: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

BACKGROUND: In 2008, the National Heart, Lung, and Blood Institute convened an Implementation Science Work Group to assess evidence-based strategies for effectively implementing clinical practice guidelines. This was part of a larger effort to update existing clinical practice guidelines on cholesterol, blood pressure, and overweight/obesity. OBJECTIVES: Review evidence from the published implementation science literature and identify effective or promising strategies to enhance the adoption and implementation of clinical practice guidelines. METHODS: This systematic review was conducted on 4 critical questions, each focusing on the adoption and effectiveness of 4 intervention strategies: (1) reminders, (2) educational outreach visits, (3) audit and feedback, and (4) provider incentives. A scoping review of the Rx for Change database of systematic reviews was used to identify promising guideline implementation interventions aimed at providers. Inclusion and exclusion criteria were developed a priori for each question, and the published literature was initially searched up to 2012, and then updated with a supplemental search to 2015. Two independent reviewers screened the returned citations to identify relevant reviews and rated the quality of each included review. RESULTS: Audit and feedback and educational outreach visits were generally effective in improving both process of care (15 of 21 reviews and 12 of 13 reviews, respectively) and clinical outcomes (7 of 12 reviews and 3 of 5 reviews, respectively). Provider incentives showed mixed effectiveness for improving both process of care (3 of 4 reviews) and clinical outcomes (3 reviews equally distributed between generally effective, mixed, and generally ineffective). Reminders showed mixed effectiveness for improving process of care outcomes (27 reviews with 11 mixed and 3 generally ineffective results) and were generally ineffective for clinical outcomes (18 reviews with 6 mixed and 9 generally ineffective results). Educational outreach visits (2 of 2 reviews), reminders (3 of 4 reviews), and provider incentives (1 of 1 review) were generally effective for cost reduction. Educational outreach visits (1 of 1 review) and provider incentives (1 of 1 review) were also generally effective for cost-effectiveness outcomes. Barriers to clinician adoption or adherence to guidelines included time constraints (8 reviews/overviews); limited staffing resources (2 overviews); timing (5 reviews/overviews); clinician skepticism (5 reviews/overviews); clinician knowledge of guidelines (4 reviews/overviews); and higher age of the clinician (1 overview). Facilitating factors included guideline characteristics such as format, resources, and end-user involvement (6 reviews/overviews); involving stakeholders (5 reviews/overviews); leadership support (5 reviews/overviews); scope of implementation (5 reviews/overviews); organizational culture such as multidisciplinary teams and low-baseline adherence (9 reviews/overviews); and electronic guidelines systems (3 reviews). CONCLUSION: The strategies of audit and feedback and educational outreach visits were generally effective in improving both process of care and clinical outcomes. Reminders and provider incentives showed mixed effectiveness, or were generally ineffective. No general conclusion could be reached about cost effectiveness, because of limitations in the evidence. Important gaps exist in the evidence on effectiveness of implementation interventions, especially regarding clinical outcomes, cost effectiveness and contextual issues affecting successful implementation.

Climate research must sharpen its view.

Human activity is changing Earth's climate. Now that this has been acknowledged and accepted in international negotiations, climate research needs to define its next frontiers.

Health Information Exchange Use (1990-2015): A Systematic Review.

BACKGROUND: In June 2014, the Office of the National Coordinator for Health Information Technology published a 10-year roadmap for the United States to achieve interoperability of electronic health records (EHR) by 2024. A key component of this strategy is the promotion of nationwide health information exchange (HIE). The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act provided significant investments to achieve HIE. OBJECTIVE: We conducted a systematic literature review to describe the use of HIE through 2015. METHODS: We searched MEDLINE, PsycINFO, CINAHL, and Cochrane databases (1990 - 2015); reference lists; and tables of contents of journals not indexed in the databases searched. We extracted data describing study design, setting, geographic location, characteristics of HIE implementation, analysis, follow-up, and results. Study quality was dual-rated using pre-specified criteria and discrepancies resolved through consensus. RESULTS: We identified 58 studies describing either level of use or primary uses of HIE. These were a mix of surveys, retrospective database analyses, descriptions of audit logs, and focus groups. Settings ranged from community-wide to multinational. Results suggest that HIE use has risen substantially over time, with 82% of non-federal hospitals exchanging information (2015), 38% of physician practices (2013), and 17-23% of long-term care facilities (2013). Statewide efforts, originally funded by HITECH, varied widely, with a small number of states providing the bulk of the data. Characteristics of greater use include the presence of an EHR, larger practice size, and larger market share of the health-system. CONCLUSIONS: Use of HIE in the United States is growing but is still limited. Opportunities remain for expansion. Characteristics of successful implementations may provide a path forward.

Primary Care Physician Designation and Response to Clinical Decision Support Reminders: A Cross-Sectional Study.

OBJECTIVE: Clinical decision support (CDS) has been shown to improve process outcomes, but over-alerting may not produce incremental benefits. We analyzed providers' response to preventive care reminders to determine if reminder response rates varied when a primary care provider (PCP) saw their own patients as compared with a partner's patients. Secondary objectives were to describe variation in PCP identification in the electronic health record (EHR) across sites, and to determine its accuracy. METHODS: We retrospectively analyzed response to preventive care reminders during visits to outpatient primary care sites over a three-month period where an EHR was used. Data on clinician requests for reminders, viewing of preventive care reminders, and response rates were stratified by whether the patient visited their own PCP, the PCP's partner, or where no PCP was listed in the EHR. We calculated the proportion of PCP identification across sites and agreement of identified PCP with an external standard. RESULTS: Of 84,937 visits, 58,482 (68.9%) were with the PCP, 10,259 (12.1%) were with the PCP's partner, and 16,196 (19.1%) had no listed PCP. Compared with PCP partner visits, visits with the patient's PCP were associated with more requested reminders (30.9% vs 22.9%), viewed reminders (29.7% vs 20.7%), and responses to reminders (28.7% vs 12.6%), all comparisons p<0.001. Visits with no listed PCP had the lowest rates of requests, views, and responses. There was good agreement between the EHR-listed PCP and the provider seen for a plurality of visits over the last year (κ=0.917). CONCLUSIONS: A PCP relationship during a visit was associated with higher use of preventive care reminders and a lack of PCP was associated with lower use of CDS. Targeting reminders to the PCP may be desirable, but further studies are needed to determine which strategy achieves better patient care outcomes.