A Systematic Approach to the Design and Implementation of Clinical Informatics Fellowship Programs.

Clinical Informatics (CI), a medical subspecialty since 2011, has grown from the initial four fellowship programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) in 2014 to more than 50 and counting in the present day. In parallel, the literature guiding Clinical Informatics Fellowship training and the curriculum evolved from the original core content published in 2009 to the more recent CI Subspecialty Delineation of Practice and the updated ACGME Milestones 2.0 for CI. In this paper, we outline this evolution and its impact on CIF Curricula. We then propose a framework, specific processes, and tools to standardize the design and optimize the implementation of CIF programs.

The rule of thirds: Determining the ideal areolar proportions.

BACKGROUND: Breast surgery often requires changing the diameter of the areola. Recommended areolar size is commonly based on population averages, or surgical judgement. An ideal areola size has not been previously been described. We hypothesized that the ideal areolar diameter would be proportional to two breast measurements not commonly altered during breast surgery: the nipple diameter and breast base width. METHODS: 'The Sun' newspaper (London, UK) publishes photographs of topless models which are selected based on the aesthetic appeal of their non-operated breasts. The publication's archive, from March 2014 to January 2017, was independently reviewed by three authors to identify photographs that presented a clear anterior view of the breast. The base width, nipple diameter and areolar diameter were measured independently by each reviewer. Measurements were pooled, and the mean was included for analysis. Ratios of the areolar diameter to the base width and the nipple diameter were calculated. RESULTS: The photographs of 58 models were eligible for inclusion. The average areolar diameter to base width was 0.29 (SD = 0.05). The average nipple to areolar diameter was 0.29 (SD = 0.06). CONCLUSIONS: In aesthetically pleasing breasts, the areolar diameter is proportional to both the breast base width and nipple diameter. Breast base width is commonly measured preoperatively in aesthetic breast procedures, and is not typically modified. Breast base width can therefore be used to determine the ideal areolar size using the ratio of areola:base width ratio of 0.29 identified in this study.

The clinician's role in promoting resiliency for individuals and families with growth anomalies.

Some recent clinic and population-based studies suggest that severe short stature is not associated with significant behavioral and psychological problems, however collectively studies on this topic are variable and frequently contradictory. In light of these contradictory sources, it is important to recognize that there may be some children for whom growth failure is disabling. Many of such children can respond to counseling and support, but there may be occasions in which therapy can be recommended. Resiliency can be defined as a pattern of positive adaptation in the context of past or present adversity with resiliency in childhood defined as typical development in the face of adverse circumstances that propel others to deleterious outcomes. Several strategies for promoting resilience in short stature patients and their families include 1) conducting a comprehensive psychosocial assessment; 2) recommending psychological strategies to directly address predictable social challenges associated with short stature; 3) discouraging the expectation that taller stature is associated with improvement in quality of life and; 4) discussing treatment efficacy in terms of the degree of certainty and magnitude of effects. Recognizing time constraints in clinical settings, these approaches can be carried out across multiple visits. Being aware of, honoring, and addressing factors the parent and patient use in making their treatment decisions has the potential to promote resiliency in patients and families. This approach to clinical care can serve to promote resiliency in clinicians as well.

Domains, tasks, and knowledge for clinical informatics subspecialty practice: results of a practice analysis.

OBJECTIVE: The study sought to develop a comprehensive and current description of what Clinical Informatics Subspecialty (CIS) physician diplomates do and what they need to know. MATERIALS AND METHODS: Three independent subject matter expert panels drawn from and representative of the 1695 CIS diplomates certified by the American Board of Preventive Medicine contributed to the development of a draft CIS delineation of practice (DoP). An online survey was distributed to all CIS diplomates in July 2018 to validate the draft DoP. A total of 316 (18.8%) diplomates completed the survey. Survey respondents provided domain, task, and knowledge and skill (KS) ratings; qualitative feedback on the completeness of the DoP; and detailed professional background and demographic information. RESULTS: This practice analysis resulted in a validated, comprehensive, and contemporary DoP comprising 5 domains, 42 tasks, and 139 KS statements. DISCUSSION: The DoP that emerged from this study differs from the 2009 CIS Core Content in 2 respects. First, the DoP reflects the growth in amount, types, and utilization of health data through the addition of a practice domain, tasks, and KS statements focused on data analytics and governance. Second, the final DoP describes CIS practice in terms of tasks in addition to identifying knowledge required for competent practice. CONCLUSIONS: This study (1) articulates CIS diplomate tasks and knowledge used in practice, (2) provides data that will enable the American Board of Preventive Medicine CIS examination to align with current practice, (3) informs clinical informatics fellowship program requirements, and (4) provides insight into maintenance of certification requirements.

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.

Rolling Tobacco in Banana Leaves, Newspaper, or Copybook Paper Associated With Significant Reduction in Lung Function in Vanuatu.

In addition to the widespread availability of packaged cigarettes, the inhabitants of island nations of the Southwest Pacific frequently smoke commercially available loose tobacco using manufactured rolling papers, as well as locally grown tobacco rolled in manufactured rolling paper or wrapped in leaves, copybook paper, and newspaper. In this study, Vanuatu men who smoked local tobacco rolled in leaves, copybook paper, or newspaper showed significantly lower forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and FEV1/FVC ratios than men who smoked packaged cigarettes, store-bought tobacco rolled in manufactured rolling paper, or who smoked locally grown tobacco rolled in manufactured rolling papers. The addition of toxins from these unusual tobacco-wrapping media produces lung function deficits similar to the pattern noted among tobacco smokers who also inhale smoke from burning biomass. Thus, public health initiatives should consider including strategies addressing the use of wrapping media among smokers in South Pacific island societies.

Milestones: Critical Elements in Clinical Informatics Fellowship Programs.

BACKGROUND: Milestones refer to points along a continuum of a competency from novice to expert. Resident and fellow assessment and program evaluation processes adopted by the ACGME include the mandate that programs report the educational progress of residents and fellows twice annually utilizing Milestones developed by a specialty specific ACGME working group of experts. Milestones in clinical training programs are largely unmapped to specific assessment tools. Residents and fellows are mainly assessed using locally derived assessment instruments. These assessments are then reviewed by the Clinical Competency Committee which assigns and reports trainee ratings using the specialty specific reporting Milestones. METHODS AND RESULTS: The challenge and opportunity facing the nascent specialty of Clinical Informatics is how to optimally utilize this framework across a growing number of accredited fellowships. The authors review how a mapped milestone framework, in which each required sub-competency is mapped to a single milestone assessment grid, can enable the use of milestones for multiple uses including individualized learning plans, fellow assessments, and program evaluation. Furthermore, such a mapped strategy will foster the ability to compare fellow progress within and between Clinical Informatics Fellowships in a structured and reliable fashion. Clinical Informatics currently has far less variability across programs and thus could easily utilize a more tightly defined set of milestones with a clear mapping to sub-competencies. This approach would enable greater standardization of assessment instruments and processes across programs while allowing for variability in how those sub-competencies are taught. CONCLUSIONS: A mapped strategy for Milestones offers significant advantages for Clinical Informatics programs.

A novel approach to supporting relationship-centered care through electronic health record ergonomic training in preclerkship medical education.

PROBLEM: How can physicians incorporate the electronic health record (EHR) into clinical practice in a relationship-enhancing fashion ("EHR ergonomics")? APPROACH: Three convenience samples of 40 second-year medical students with varying levels of EHR ergonomic training were compared in the 2012 spring semester. All participants first received basic EHR training and completed a presurvey. Two study groups were then instructed to use the EHR during the standardized patient (SP) encounter in each of four regularly scheduled Doctoring (clinical skills) course sessions. One group received additional ergonomic training in each session. Ergonomic assessment data were collected from students, faculty, and SPs in each session. A postsurvey was administered to all students, and data were compared across all three groups to assess the impact of EHR use and ergonomic training. OUTCOMES: There was a significant positive effect of EHR ergonomics skills training on students' relationship-centered EHR use (P<.005). Students who received training reported that they were able to use the EHR to engage with patients more effectively, better articulate the benefits of using the EHR, better address patient concerns, more appropriately position the EHR device, and more effectively integrate the EHR into patient encounters. Additionally, students' self-assessments were strongly corroborated by SP and faculty assessments. A minimum of three ergonomic training sessions were needed to see an overall improvement in EHR use. NEXT STEPS: In addition to replication of these results, further effectiveness studies of this educational intervention need to be carried out in GME, practice, and other environments.

Setting research priorities for patients on or nearing dialysis.

With increasing emphasis among health care providers and funders on patient-centered care, it follows that patients and their caregivers should be included when priorities for research are being established. This study sought to identify the most important unanswered questions about the management of kidney failure from the perspective of adult patients on or nearing dialysis, their caregivers, and the health care professionals who care for these patients. Research uncertainties were identified through a national Canadian survey of adult patients on or nearing dialysis, their caregivers, and health care professionals. Uncertainties were refined by a steering committee that included patients, caregivers, researchers, and clinicians to assemble a short-list of the top 30 uncertainties. Thirty-four people (11 patients; five caregivers; eight physicians; six nurses; and one social worker, pharmacist, physiotherapist, and dietitian each) from across Canada subsequently participated in a workshop to determine the top 10 research questions. In total, 1570 usable research uncertainties were received from 317 respondents to the survey. Among these, 259 unique uncertainties were identified; after ranking, these were reduced to a short-list of 30 uncertainties. During the in-person workshop, the top 10 research uncertainties were identified, which included questions about enhanced communication among patients and providers, dialysis modality options, itching, access to kidney transplantation, heart health, dietary restrictions, depression, and vascular access. These can be used alongside the results of other research priority-setting exercises to guide researchers in designing future studies and inform health care funders.

The evolution of a novel biomedical informatics curriculum for medical students.

Health information technology is an essential component of current medical practice, and federal initiatives to promote the further adoption of these technologies are under way. Therefore, it is increasingly important that medical students receive training in the use of these technologies and become familiar with the discipline of biomedical informatics (BMI), which seeks to maximize the utility of health information. In August 2007, the University of Arizona College of Medicine established a new four-year medical school campus in Phoenix. At the same time, a new BMI department was created by the Arizona State University on the same campus. One of the unique features of the new medical school curriculum was a significant focus on BMI, consisting of over 45 hours of required sequenced and integrated instruction in BMI topics. This article describes how the medical school curriculum was created, what BMI elements were contained within the curriculum, and how the instruction was provided. Evaluation of the curriculum included subjective and objective components and revealed significant differences both within group (pre- and posttraining) and across groups when compared with students without formal BMI training. Specifically, self-assessment of BMI ability increased after exposure to the curriculum, and students receiving the BMI curriculum were able to answer objective questions related to BMI content. Implications and lessons learned in the implementation are also discussed.

Incorporation of spatial and economic analyses of human-use data in the design of marine protected areas.

Social, economic, and ecological criteria contribute to the successful design, implementation, and management of marine protected areas (MPAs). In the context of California's Marine Life Protection Act Initiative, we developed a set of methods for collecting, compiling, and analyzing data about the spatial extent and relative economic importance of commercial and recreational fishing. We interviewed 174 commercial fishers who represented the major fisheries in the initiative's north-central coast region, which extends from Point Arena south to Pigeon Point. These fishers provided data that we used to map the extent of each of the fishing grounds, to weight the relative importance of areas within the grounds, to characterize the operating costs of each fishery, and to analyze the potential economic losses associated with proposed marine protected areas. A regional stakeholder group used the maps and impact analyses in conjunction with other data sets to iteratively identify economic and ecological trade-offs in designations of different areas as MPAs at regional, port, and fishery extents. Their final proposed MPA network designated 20% of state waters as MPAs. Potential net economic loss ranged from 1.7% to 14.2% in the first round of network design and totaled 6.3% in the final round of design. This process is a case study in the application of spatial analysis to validate and integrate local stakeholder knowledge in marine planning.

Not all salmon are created equal: life cycle assessment (LCA) of global salmon farming systems.

We present a global-scale life cycle assessment of a major food commodity, farmed salmon. Specifically, we report the cumulative energy use, biotic resource use, and greenhouse gas, acidifying, and eutrophying emissions associated with producing farmed salmon in Norway, the UK, British Columbia (Canada), and Chile, as well as a production-weighted global average. We found marked differences in the nature and quantity of material/energy resource use and associated emissions per unit production across regions. This suggests significant scope for improved environmental performance in the industry as a whole. We identify key leverage points for improving performance, most notably the critical importance of least-environmental cost feed sourcing patterns and continued improvements in feed conversion efficiency. Overall, impacts were lowest for Norwegian production in most impact categories, and highest for UK farmed salmon. Our results are of direct relevance to industry, policy makers, eco-labeling programs, and consumers seeking to further sustainability objectives in salmon aquaculture.

The University of Victoria Interdisciplinary Electronic Health Record Educational Portal.

Use of Electronic Health Record (EHR) systems is increasing globally. However, adoption rates of Health Information Systems (HISs) continue to remain poor. To improve adoption rates, there is need to provide greater HIS experience to health professionals and informaticians in health and biomedicine during their undergraduate and graduate education. A recent review of the health professional educational curricula (i.e., medicine, nursing, allied health and health/biomedical informatics) revealed that they provide only limited exposure to EHRs. In response to this educational need, the authors have developed the University of Victoria Interdisciplinary Electronic Health Record Educational Portal (UVicIED-EHR Portal). This unique, web-based portal allows students of the health professions and practicing professionals to access and interact with a set of representative EHR HIS solutions using the web. The portal, which links to several EMRs, EPRs and PHRs, has been used by several health professional educational programs in medicine, nursing and health informatics. It provides practicing health and health/biomedical informatics professionals, for example, managers and directors, with opportunities to access and review EHR systems. The portal has been used successfully in the classroom, laboratory and with distance education to give hands-on experience with a variety of HISs and their components.

The FLYWCH transcription factors FLH-1, FLH-2, and FLH-3 repress embryonic expression of microRNA genes in C. elegans.

MicroRNAs (miRNAs) are small noncoding RNAs that regulate gene expression post-transcriptionally via antisense base-pairing. Although miRNAs are involved in a variety of important biological functions, little is known about their transcriptional regulation. Using yeast one-hybrid assays, we identified transcription factors with a FLYWCH Zn-finger DNA-binding domain that bind to the promoters of several Caenorhabditis elegans miRNA genes. The products of the flh-1 and flh-2 genes function redundantly to repress embryonic expression of lin-4, mir-48, and mir-241, miRNA genes that are normally expressed only post-embryonically. Although single mutations in either flh-1 or flh-2 genes result in a viable phenotype, double mutation of flh-1 and flh-2 results in early larval lethality and an enhanced derepression of their target miRNAs in embryos. Double mutations in flh-2 and a third FLYWCH Zn-finger-containing transcription factor, flh-3, also result in enhanced precocious expression of target miRNAs. Mutations of lin-4 or mir-48&mir-241 do not rescue the lethal flh-1; flh-2 double-mutant phenotype, suggesting that the inviability is not solely the result of precocious expression of these miRNAs. Therefore, the FLH-1 and FLH-2 proteins likely play a more general role in regulating gene expression in embryos.

The integrative family medicine program: an innovation in residency education.

The Integrative Family Medicine (IFM) Program is a four-year combined family medicine residency program and integrative medicine fellowship. It was created in 2003 to address the needs of four constituencies: patients who desire care from well trained integrative physicians, physicians who seek such training, the health care system which lacks a conventional integrative medicine training route, and educational leaders in family medicine who are seeking new strategies to reverse the declining interest in family medicine amongst U.S. graduates. The program was designed jointly by the University of Arizona Program in Integrative Medicine (PIM) and family medicine residency programs at Beth Israel/Albert Einstein College of Medicine (AECOM), Maine Medical Center, Middlesex Hospital, Oregon Health & Science University, and the Universities of Arizona and Wisconsin. One or two residents from each of these institutions may apply, and when selected, commit to extending their training by a fourth year. They complete their family medicine residencies at their home sites, enroll in the distributed learning associate fellowship at PIM, and are mentored by local faculty members who have training in integrative medicine. To date three classes totaling twenty residents have entered the program. Evaluation is performed jointly: PIM evaluates the residents during residential weeks and through online modules and residency faculty members perform direct observation of care and review treatment plans. Preliminary data suggest that the program enhances interest amongst graduating medical students in family medicine training. The Accreditation Council of Graduate Medical Education Family Medicine residency review committee has awarded the pilot experimental status.

The contribution of tandem repeat number to the O-glycosylation of mucins.

The serine- and threonine-rich tandem repeat (TR) units that make up the characteristic feature of mucin glycoproteins are often polymorphic with substantial genetic variation in TR number. The precise effect of TR number on O-glycosylation is not fully understood, although the TR number of several mucins may be associated with apparent susceptibility to certain human diseases. To evaluate the contribution of TR number to O-glycosylation, we generated a series of chimeric mucins carrying increasing numbers of TR units from the MUC5B mucin in the context of an epitope-tagged MUC1 mucin backbone. These mucins were expressed in Caco2 colon carcinoma cell clones and purified by immunoprecipitation. O-Glycosylation was investigated by western blotting with antibodies to known carbohydrate structures and by fast atom bombardment-mass spectrometry. Additional carbohydrate epitopes were detected with antibodies on chimeric mucins with a higher TR number in comparison to those with fewer TRs. Using mass spectrometry, higher-molecular-weight glycans were detected more frequently on the mucins with extended TRs compared to those with fewer TRs. However no novel carbohydrate structures were seen, suggesting that TR number does not affect the specificity of O-glycosylation.

In vivo glycosylation of MUC1 in airway epithelial cells.

The O-glycans that decorate mucin glycoproteins contribute to the biophysical and biochemical properties of these molecules and hence their function as a barrier and lubricant on epithelial surfaces. Alterations in mucin O-glycosylation in certain diseases may contribute to pathology. It is known that both the host cell type and the amino acid sequence of the mucin tandem repeat contribute to the O-glycosylation of a mucin molecule. We expressed an epitope-tagged MUC1 mucin cDNA construct in the airway cell line 16HBE14o- and the colon carcinoma cell line Caco2 and used Fast Atom Bombardment Mass Spectrometry to evaluate the contribution of the host cell to differences in O-glycosylation of a single mucin. Many of the glycans detected on the MUC1 mucin were common to both cell types, as would be predicted from biosynthetic constraints. However, MUC1 synthesized in the airway cell line showed comparatively low levels of sialylation but carried a range of oligo-N-acetyllactosamine structures that were not seen in the colon carcinoma cell line.