Long-term assessment of the environmental fate of heavy metals in agricultural soil after cessation of organic waste treatments.

The current study examined the anthropogenic accumulation and natural decrease in metal concentrations in agricultural soils following organic waste application. Three common organic wastes, including municipal sewage sludge, alcohol fermentation processing sludge, and pig manure compost (PMC), were applied annually to an agricultural soil under field conditions over 7 years (1994-2000) at a rate of 12.5, 25, and 50 ton ha(-1) year(-1) and the soil accumulation of three metals of concern (Cu, Pb, and Zn) was monitored. Subsequently, organic waste amendments ceased and the experimental plots were managed using conventional fertilization for another 10 years (2001-2010) and the natural decrease in metal concentrations monitored. Although Cu and Zn concentrations in all experimental plots did not exceed the relevant guideline values (150 mg kg(-1) for Cu and 300 mg kg(-1) for Zn), significant increases in metal concentrations were observed from cumulative application of organic wastes over 7 years. For instance, PMC treatment resulted in an increase in Cu and Zn from 9.8 and 72 mg kg(-1) to 108.2 and 214.3 mg kg(-1), respectively. In addition, the natural decrease in Cu and Zn was not significant as soils amended with PMC showed only a 16 and 19 % decline in Cu and Zn concentrations, respectively, even 10 years after amendment ceased. This research suggested that more attention must be paid during production of organic waste-based amendments and at the application stage.

Return on investment in electronic health records in primary care practices: a mixed-methods study.

BACKGROUND: The use of electronic health records (EHR) in clinical settings is considered pivotal to a patient-centered health care delivery system. However, uncertainty in cost recovery from EHR investments remains a significant concern in primary care practices. OBJECTIVE: Guided by the question of "When implemented in primary care practices, what will be the return on investment (ROI) from an EHR implementation?", the objectives of this study are two-fold: (1) to assess ROI from EHR in primary care practices and (2) to identify principal factors affecting the realization of positive ROI from EHR. We used a break-even point, that is, the time required to achieve cost recovery from an EHR investment, as an ROI indicator of an EHR investment. METHODS: Given the complexity exhibited by most EHR implementation projects, this study adopted a retrospective mixed-method research approach, particularly a multiphase study design approach. For this study, data were collected from community-based primary care clinics using EHR systems. RESULTS: We collected data from 17 primary care clinics using EHR systems. Our data show that the sampled primary care clinics recovered their EHR investments within an average period of 10 months (95% CI 6.2-17.4 months), seeing more patients with an average increase of 27% in the active-patients-to-clinician-FTE (full time equivalent) ratio and an average increase of 10% in the active-patients-to-clinical-support-staff-FTE ratio after an EHR implementation. Our analysis suggests, with a 95% confidence level, that the increase in the number of active patients (P=.006), the increase in the active-patients-to-clinician-FTE ratio (P<.001), and the increase in the clinic net revenue (P<.001) are positively associated with the EHR implementation, likely contributing substantially to an average break-even point of 10 months. CONCLUSIONS: We found that primary care clinics can realize a positive ROI with EHR. Our analysis of the variances in the time required to achieve cost recovery from EHR investments suggests that a positive ROI does not appear automatically upon implementing an EHR and that a clinic's ability to leverage EHR for process changes seems to play a role. Policies that provide support to help primary care practices successfully make EHR-enabled changes, such as support of clinic workflow optimization with an EHR system, could facilitate the realization of positive ROI from EHR in primary care practices.

The Scleroderma Patient-centered Intervention Network (SPIN) Cohort: protocol for a cohort multiple randomised controlled trial (cmRCT) design to support trials of psychosocial and rehabilitation interventions in a rare disease context.

INTRODUCTION: Psychosocial and rehabilitation interventions are increasingly used to attenuate disability and improve health-related quality of life (HRQL) in chronic diseases, but are typically not available for patients with rare diseases. Conducting rigorous, adequately powered trials of these interventions for patients with rare diseases is difficult. The Scleroderma Patient-centered Intervention Network (SPIN) is an international collaboration of patient organisations, clinicians and researchers. The aim of SPIN is to develop a research infrastructure to test accessible, low-cost self-guided online interventions to reduce disability and improve HRQL for people living with the rare disease systemic sclerosis (SSc or scleroderma). Once tested, effective interventions will be made accessible through patient organisations partnering with SPIN. METHODS AND ANALYSIS: SPIN will employ the cohort multiple randomised controlled trial (cmRCT) design, in which patients consent to participate in a cohort for ongoing data collection. The aim is to recruit 1500-2000 patients from centres across the world within a period of 5 years (2013-2018). Eligible participants are persons ≥18 years of age with a diagnosis of SSc. In addition to baseline medical data, participants will complete patient-reported outcome measures every 3 months. Upon enrolment in the cohort, patients will consent to be contacted in the future to participate in intervention research and to allow their data to be used for comparison purposes for interventions tested with other cohort participants. Once interventions are developed, patients from the cohort will be randomly selected and offered interventions as part of pragmatic RCTs. Outcomes from patients offered interventions will be compared with outcomes from trial-eligible patients who are not offered the interventions. ETHICS AND DISSEMINATION: The use of the cmRCT design, the development of self-guided online interventions and partnerships with patient organisations will allow SPIN to develop, rigourously test and effectively disseminate psychosocial and rehabilitation interventions for people with SSc.

Policy initiatives for health information technology: a qualitative study of U.S. expectations and Canada's experience.

OBJECTIVE: To investigate lessons learned from national policy initiatives in Canada and U.S. with respect to health information technical infrastructure, data standards, and interoperability; and to identify the implications of these lessons for other policy makers, as they guide the future of their own healthcare information technology initiatives. MATERIALS AND METHODS: We performed semi-structured interviews with key opinion leaders including health care professionals, chief information officers, and vendors - 29 in Canada and 31 in the U.S., regarding Health Information Technology policy. The informant sample was chosen to provide views from different stakeholder groups, and included both national and regional representation - three Canadian provinces and three U.S. states. A grounded theory approach was used to analyze the data gathered through the interviews. RESULTS: The informants identified the following key components of successful health IT policy: (1) enables an iterative-incremental management approach to both technology and data standards, (2) addresses the issues around meaningful use and investment already made in existing legacy health IT systems; and (3) capitalizes on the value of data for use in performance and quality measures, public health and research. CONCLUSIONS: Our study has found that successful health information exchange depends on policies that set clear goals and outline intended effects of HIT implementation without being overly prescriptive, and defines frameworks for guiding policy improvement in a continual and systematic manner. The success of health information exchange also depends on the ability to manage an iterative-incremental approach to technology and data standards, starting from small data sets with high impact on specific care and then gradually expanding toward more comprehensive data sets with an increased emphasis on secondary uses of data.

Lessons from the Canadian national health information technology plan for the United States: opinions of key Canadian experts.

OBJECTIVE: To summarize the Canadian health information technology (HIT) policy experience and impart lessons learned to the US as it determines its policy in this area. DESIGN: Qualitative analysis of interviews with identified key stakeholders followed by an electronic survey. MEASUREMENTS: We conducted semi-structured interviews with 29 key Canadian HIT policy and opinion leaders and used a grounded theory approach to analyze the results. The informant sample was chosen to provide views from different stakeholder groups including national representatives and regional representatives from three Canadian provinces. RESULTS: Canadian informants believed that much of the current US direction is positive, especially regarding incentives and meaningful use, but that there are key opportunities for the US to emphasize direct engagement with providers, define a clear business case for them, sponsor large scale evaluations to assess HIT impact in a broad array of settings, determine standards but also enable access to resources needed for mid-course corrections of standards when issues are identified, and, finally, leverage implementation of digital imaging systems. LIMITATIONS: Not all stakeholder groups were included, such as providers or patients. In addition, as in all qualitative research, a selection bias could be present due to the relatively small sample size. CONCLUSIONS: Based on Canadian experience with HIT policy, stakeholders identified as lessons for the US the need to increase direct engagement with providers and the importance of defining the business case for HIT, which can be achieved through large scale evaluations, and of recognizing and leveraging successes as they emerge.

A qualitative study of Canada's experience with the implementation of electronic health information technology.

BACKGROUND: In 2001, Canada Health Infoway unveiled a plan to implement a national system of interoperable electronic health records. This government-funded corporation introduced a novel model for interprovincial/territorial collaboration to establish core aspects of a national framework. Despite this $1.6 billion initiative, Canada continues to lag behind other Western countries in adopting electronic health records. We conducted a study to identify the success of different aspects of the Canadian plan and ways to improve the adoption of electronic health records. METHODS: We used a case study approach to assess the 10-year history of Canada's e-health plan. National reports and documents were reviewed, and structured interviews were conducted with 29 key stakeholders representing national and provincial organizations responsible for establishing policy and strategic direction for health information technology. Using grounded theory, we analyzed transcripts of the interviews to identify themes and their relationships. RESULTS: Key stakeholders identified funding, national standards, patient registries and digital imaging as important achievements of the e-health plan. Lack of an e-health policy, inadequate involvement of clinicians, failure to establish a business case for using electronic health records, a focus on national rather than regional interoperability, and inflexibility in approach were seen as barriers to adoption of the plan. INTERPRETATION: To accelerate adoption of electronic health records and timely return on investment, an e-health policy needs to be tightly aligned with the major strategic directions of health care reform. Adoption needs to be actively fostered through a bottom-up, clinical-needs-first approach, a national policy for investment in electronic health records, and financial incentives based on patient outcomes that can be achieved with electronic health records.