Validating Visual Stimuli of Nature Images and Identifying the Representative Characteristics.

This study fills a void in the literature by both validating images of nature for use in future research experiments and examining which characteristics of these visual stimuli are found to be most representative of nature. We utilized a convenience sample of university students to assess 129 different nature images on which best represented nature. Participants (n = 40) viewed one image per question (n = 129) and were asked to rate images using a 5-point Likert scale, with the anchors "best represents nature" (5) and "least represents nature" (1). Average ratings across participants were calculated for each image. Canopies, mountains, bodies of water, and unnatural elements were identified as semantic categories of interest, as well as atmospheric perspectives and close-range views. We conducted the ordinary least squares (OLS) regression and the ordered logistic regression analyses to identify semantic categories highly representative of nature, controlling for the presence/absence of other semantic categories. The results showed that canopies, bodies of water, and mountains were found to be highly representative of nature, whereas unnatural elements and close-range views were inversely related. Understanding semantic categories most representative of nature is useful in developing nature-centered interventions in behavioral performance research and other neuroimaging modalities. All images are housed in an online repository and we welcome the use of the final 10 highly representative nature images by other researchers, which will hopefully prompt and expedite future examinations of nature across multiple research formats.

Assessing Patient Needs During Natural Disasters: Mixed Methods Analysis of Portal Messages Sent During Hurricane Harvey.

BACKGROUND: Patient portals play an important role in connecting patients with their medical care team, which improves patient engagement in treatment plans, decreases unnecessary visits, and reduces costs. During natural disasters, patients' needs increase, whereas available resources, specifically access to care, become limited. OBJECTIVE: This study aims to examine patients' health needs during a natural crisis by analyzing the electronic messages sent during Hurricane Harvey to guide future disaster planning efforts. METHODS: We explored patient portal use data from a large Greater Houston area health care system focusing on the initial week of the Hurricane Harvey disaster, beginning with the date of landfall, August 25, 2017, to August 31, 2017. A mixed methods approach was used to assess patients' immediate health needs and concerns during the disruption of access to routine and emergent medical care. Quantitative analysis used logistic regression models to assess the predictive characteristics of patients using the portal during Hurricane Harvey. This study also included encounters by type (emergency, inpatient, observation, outpatient, and outpatient surgery) and time (before, during, and after Hurricane Harvey). For qualitative analysis, the content of these messages was examined using the constant comparative method to identify emerging themes found within the message texts. RESULTS: Out of a total of 557,024 patients, 4079 (0.73%) sent a message during Hurricane Harvey, whereas 31,737 (5.69%) used the portal. Age, sex, race, and ethnicity were predictive factors for using the portal and sending a message during the natural disaster. We found that prior use of the patient portal increased the likelihood of portal use during Hurricane Harvey (odds ratio 13.688, 95% CI 12.929-14.491) and of sending a portal message during the disaster (odds ratio 14.172, 95% CI 11.879-16.907). Having an encounter 4 weeks before or after Hurricane Harvey was positively associated with increased use of the portal and sending a portal message. Patients with encounters during the main Hurricane Harvey week had a higher increased likelihood of portal use across all five encounter types. Qualitative themes included: access, prescription requests, medical advice (chronic conditions, acute care, urgent needs, and Hurricane Harvey-related injuries), mental health, technical difficulties, and provider constraints. CONCLUSIONS: The patient portal can be a useful tool for communication between patients and providers to address the urgent needs and concerns of patients as a natural disaster unfolds. This was the first known study to include encounter data to understand portal use compared with care provisioning. Prior use was predictive of both portal use and message sending during Hurricane Harvey. These findings could inform the types of demands that may arise in future disaster situations and can serve as the first step in intentionally optimizing patient portal usability for emergency health care management during natural disasters.

Quantifying Patient Portal Use: Systematic Review of Utilization Metrics.

BACKGROUND: Use of patient portals has been associated with positive outcomes in patient engagement and satisfaction. Portal studies have also connected portal use, as well as the nature of users' interactions with portals, and the contents of their generated data to meaningful cost and quality outcomes. Incentive programs in the United States have encouraged uptake of health information technology, including patient portals, by setting standards for meaningful use of such technology. However, despite widespread interest in patient portal use and adoption, studies on patient portals differ in actual metrics used to operationalize and track utilization, leading to unsystematic and incommensurable characterizations of use. No known review has systematically assessed the measurements used to investigate patient portal utilization. OBJECTIVE: The objective of this study was to apply systematic review criteria to identify and compare methods for quantifying and reporting patient portal use. METHODS: Original studies with quantifiable metrics of portal use published in English between 2014 and the search date of October 17, 2018, were obtained from PubMed using the Medical Subject Heading term "Patient Portals" and related keyword searches. The first search round included full text review of all results to confirm a priori data charting elements of interest and suggest additional categories inductively; this round was supplemented by the retrieval of works cited in systematic reviews (based on title screening of all citations). An additional search round included broader keywords identified during the full-text review of the first round. Second round results were screened at abstract level for inclusion and confirmed by at least two raters. Included studies were analyzed for metrics related to basic use/adoption, frequency of use, duration metrics, intensity of use, and stratification of users into "super user" or high utilizers. Additional categories related to provider (including care team/administrative) use of the portal were identified inductively. Additional analyses included metrics aligned with meaningful use stage 2 (MU-2) categories employed by the US Centers for Medicare and Medicaid Services and the association between the number of portal metrics examined and the number of citations and the journal impact factor. RESULTS: Of 315 distinct search results, 87 met the inclusion criteria. Of the a priori metrics, plus provider use, most studies included either three (26 studies, 30%) or four (23 studies, 26%) metrics. Nine studies (10%) only reported the patient use/adoption metric and only one study (1%) reported all six metrics. Of the US-based studies (n=76), 18 (24%) were explicitly motivated by MU-2 compliance; 40 studies (53%) at least mentioned these incentives, but only 6 studies (8%) presented metrics from which compliance rates could be inferred. Finally, the number of metrics examined was not associated with either the number of citations or the publishing journal's impact factor. CONCLUSIONS: Portal utilization measures in the research literature can fall below established standards for "meaningful" or they can substantively exceed those standards in the type and number of utilization properties measured. Understanding how patient portal use has been defined and operationalized may encourage more consistent, well-defined, and perhaps more meaningful standards for utilization, informing future portal development.

Ethical Considerations When Using a Mobile Eye Tracker in a Patient-Facing Area: Lessons from an Intensive Care Unit Observational Protocol.

This article describes the process of designing, approving, and conducting an investigator-initiated protocol to use an eye-tracking device in a health care setting. Participants wore the device, which resembles eyeglasses, in a front-facing manner in an intensive care unit for the study of personnel gaze patterns, producing a visual record of workflow. While the data of interest for our study was not specifically the health information protected by the privacy rule of the Health Insurance Portability and Accountability Act (HIPAA), a wide variety of such data was captured by the eye-tracking device, and the prospective consent of all people who might have been incidentally videotaped was not feasible. The protocol therefore required attention to unique ethical considerations-including consent, privacy and confidentiality, HIPAA compliance, institutional liability, and the use of secondary data. The richness of eye-tracker data suggests various beneficial applications in health care occupational research and quality improvement. Therefore, sharing our study's successful design and execution, including proactive researcher-institutional review board communication, can inform and encourage similarly valuable, ethical, and innovative audiovisual research techniques.

Adapting an Outpatient Psychiatric Clinic to Telehealth During the COVID-19 Pandemic: A Practice Perspective.

As the demand for telepsychiatry increases during the COVID-19 pandemic, the strengths and challenges of telepsychiatry implementation must be articulated to improve clinical practices in the long term. Currently, observations within US contexts are lacking; therefore, we report on the rapid implementation of telepsychiatry and workflow experiences in a psychiatric practice based within a large health care system in southeast Texas with a national catchment area. We discuss the logistics of the implementation, including modes of communication, scheduling, coordination, and capacity; the psychological effects of web-based services, including both the loss of the physical therapeutic environment and the unique interpersonal dynamics experienced in the virtual environment; and postadoption patterns of engagement with our services and with other clinical functions affected by the rapid adaptation to telemedicine. Our art therapy group programming serves as an applied case study, demonstrating the value of a well-managed web-based program (eg, patients were receptive and well-engaged, and they appreciated the continuity of accessible service) as well as the challenges (eg, the need for backup plans and technological fallbacks, managing interruptions and telecommunication learning curves, and working around the difference in resources for art and music therapy between a well-stocked clinical setting versus clients' home spaces). We conclude from our experience that the overall strengths of telepsychiatry include receptive and well-engaged responses from patients as well as the expansion of boundaries, which provides a directly contextualized view into patients' home lives. Challenges and corresponding recommendations include the need for more careful safety planning for high-risk patients; maintaining professional boundaries in the newly informal virtual setting; designing the physical space to both frame the patient encounter and maintain work-life balance for the therapist; allowing for delays and interruptions (including an initial acclimation session); and preserving interprofessional care team collaboration when the physical locations that normally facilitate such encounters are not accessible. We believe that careful observations of the strengths and challenges of telepsychiatry during this pandemic will better inform practices that are considering telepsychiatry adoption both within pandemic contexts and more broadly thereafter.

Six Values Never to Silence: Jewish Perspectives on Nazi Medical Professionalism.

An ideological case study based on medical profession norms during the Third Reich will be used to exemplify the importance of diversity in the manifestations of professional ethics. The German professional medical community banned their Jewish colleagues from treating German citizens. This included legally mandated employment discrimination and outright censure which led to a professional ethic devoid of diverse voices. While the escalation to the T-4 program and medicalized genocide was influenced by many causes, the intentional, ethnocentric-based exclusion of voices was an important contributing element to the chronicled degradation of societal mores. For illustration, six core Jewish values-life, peace, justice, mercy, scholarship, and sincerity of intention-will be detailed for their potential to inspire health-care professionals to defend and protect minorities and for readers to think critically about the role of medical professionalism in Third Reich society. The Jewish teachings highlight the inherent professional obligations physicians have toward their patients in contrast to the Third Reich's corruption of patient-centered professionalism. More fundamentally, juxtaposing Jewish and Nazi teachings exposes the loss of perspective when a profession's identity spurns diversity. To ensure respect for persons in all vulnerable minorities, the first step is addressing professional inclusion of minority voices.

Conflicts among multinational ethical and scientific standards for clinical trials of therapeutic interventions.

Utilizing a sorted compendium of international clinical trial standards, investigators identified 15 conflicts among ethical and methodological guidance. Analysis distinguishes interpretational issues, lack of clarity, and contradiction as factors to be addressed if international trial guidance is to be improved.

A taxonomy of multinational ethical and methodological standards for clinical trials of therapeutic interventions.

BACKGROUND: If trials of therapeutic interventions are to serve society's interests, they must be of high methodological quality and must satisfy moral commitments to human subjects. The authors set out to develop a clinical-trials compendium in which standards for the ethical treatment of human subjects are integrated with standards for research methods. METHODS: The authors rank-ordered the world's nations and chose the 31 with >700 active trials as of 24 July 2008. Governmental and other authoritative entities of the 31 countries were searched, and 1004 English-language documents containing ethical and/or methodological standards for clinical trials were identified. The authors extracted standards from 144 of those: 50 designated as 'core', 39 addressing trials of invasive procedures and a 5% sample (N=55) of the remainder. As the integrating framework for the standards we developed a coherent taxonomy encompassing all elements of a trial's stages. FINDINGS: Review of the 144 documents yielded nearly 15 000 discrete standards. After duplicates were removed, 5903 substantive standards remained, distributed in the taxonomy as follows: initiation, 1401 standards, 8 divisions; design, 1869 standards, 16 divisions; conduct, 1473 standards, 8 divisions; analysing and reporting results, 997 standards, four divisions; and post-trial standards, 168 standards, 5 divisions. CONCLUSIONS: The overwhelming number of source documents and standards uncovered in this study was not anticipated beforehand and confirms the extraordinary complexity of the clinical trials enterprise. This taxonomy of multinational ethical and methodological standards may help trialists and overseers improve the quality of clinical trials, particularly given the globalisation of clinical research.