VACtrac: enhancing access immunization registry data for population outreach using the Bulk Fast Healthcare Interoperable Resource (FHIR) protocol.

COVID-19 vaccination uptake has been suboptimal, even in high-risk populations. New approaches are needed to bring vaccination data to the groups leading outreach efforts. This article describes work to make state-level vaccination data more accessible by extending the Bulk Fast Healthcare Interoperability Resource (FHIR) standard to better support the repeated retrieval of vaccination data for coordinated outreach efforts. We also describe a corresponding low-foot-print software for population outreach that automates repeated checks of state-level immunization data and prioritizes outreach by social determinants of health. Together this software offers an integrated approach to addressing vaccination gaps. Several extensions to the Bulk FHIR protocol were needed to support bulk query of immunization records. These are described in detail. The results of a pilot study, using the outreach tool to target a population of 1500 patients are also described. The results confirmed the limitations of current patient-by-patient approach for querying state immunizations systems for population data and the feasibility of a Bulk FHIR approach.

Automated production of research data marts from a canonical fast healthcare interoperability resource data repository: applications to COVID-19 research.

OBJECTIVE: The rapidly evolving COVID-19 pandemic has created a need for timely data from the healthcare systems for research. To meet this need, several large new data consortia have been developed that require frequent updating and sharing of electronic health record (EHR) data in different common data models (CDMs) to create multi-institutional databases for research. Traditionally, each CDM has had a custom pipeline for extract, transform, and load operations for production and incremental updates of data feeds to the networks from raw EHR data. However, the demands of COVID-19 research for timely data are far higher, and the requirements for updating faster than previous collaborative research using national data networks have increased. New approaches need to be developed to address these demands. METHODS: In this article, we describe the use of the Fast Healthcare Interoperability Resource (FHIR) data model as a canonical data model and the automated transformation of clinical data to the Patient-Centered Outcomes Research Network (PCORnet) and Observational Medical Outcomes Partnership (OMOP) CDMs for data sharing and research collaboration on COVID-19. RESULTS: FHIR data resources could be transformed to operational PCORnet and OMOP CDMs with minimal production delays through a combination of real-time and postprocessing steps, leveraging the FHIR data subscription feature. CONCLUSIONS: The approach leverages evolving standards for the availability of EHR data developed to facilitate data exchange under the 21st Century Cures Act and could greatly enhance the availability of standardized datasets for research.

Informatics for public health and health system collaboration: Applications for the control of the current COVID-19 pandemic and the next one.

Public health faces unprecedented challenges in its efforts to control COVID-19 through a national vaccination campaign. Addressing these challenges will require fundamental changes to public health data systems. For example, of the core data systems for immunization campaigns is the immunization information system (IIS); however, IISs were designed for tracking the vaccinated, not finding the patients who are high risk and need to be vaccinated. Health systems have this data in their electronic health records (EHR) systems and often have a greater capacity for outreach. Clearly, a partnership is needed. However, successful collaborations will require public health to change from its historical hierarchical information supply chain model to an ecosystem model with a peer-to-peer exchange with population health providers. Examples of the types of informatics innovations necessary to support such an ecosystem include a national patient identifier, population-level data exchange for immunization data, and computable electronic quality measures. Rather than think of these components individually, a comprehensive approach to rapidly adaptable tools for collaboration is needed.

Automated Production of Research Data Marts from a Canonical Fast Healthcare Interoperability Resource (FHIR) Data Repository: Applications to COVID-19 Research.

OBJECTIVE: Objective: The COVID-19 pandemic has enhanced the need for timely real-world data (RWD) for research. To meet this need, several large clinical consortia have developed networks for access to RWD from electronic health records (EHR), each with its own common data model (CDM) and custom pipeline for extraction, transformation, and load operations for production and incremental updating. However, the demands of COVID-19 research for timely RWD (e.g., 2-week delay) make this less feasible. METHODS AND MATERIALS: We describe the use of the Fast Healthcare Interoperability Resource (FHIR) data model as a canonical model for representation of clinical data for automated transformation to the Patient-Centered Outcomes Research Network (PCORnet) and Observational Medical Outcomes Partnership (OMOP) CDMs and the near automated production of linked clinical data repositories (CDRs) for COVID-19 research using the FHIR subscription standard. The approach was applied to healthcare data from a large academic institution and was evaluated using published quality assessment tools. RESULTS: Six years of data (1.07M patients, 10.1M encounters, 137M laboratory results), were loaded into the FHIR CDR producing 3 linked real-time linked repositories: FHIR, PCORnet, and OMOP. PCORnet and OMOP databases were refined in subsequent post processing steps into production releases and met published quality standards. The approach greatly reduced CDM production efforts. CONCLUSIONS: FHIR and FHIR CDRs can play an important role in enhancing the availability of RWD from EHR systems. The above approach leverages 21 st Century Cures Act mandated standards and could greatly enhance the availability of datasets for research.

The Advocacy Journal Club.

OBJECTIVES: To describe a method of educating pathologists about health policy. METHODS: The Advocacy Journal Club was a series of six conferences. Topics were of those in the news or affecting local practice. Participants reviewed preparatory readings, completed a six- to 10-question pretest, attended an interactive presentation stressing advocacy groups' efforts, and completed a posttest. All were invited to complete a survey after the sessions. RESULTS: Faculty and residents had increased posttest scores following each presentation with a significant difference in four and three sessions, respectively. More than 80% agreed they could discuss the topics with others and understood how regulations affect practice. More than 90% agreed that they gained an understanding of how involvement in organizations' advocacy initiatives affects policy. CONCLUSIONS: We present a method for educating pathologists about policy and the role of professional societies that could be implemented by nearly all graduate medical education programs.

Conversion From Off-Pump Coronary Artery Bypass Grafting to On-Pump Coronary Artery Bypass Grafting.

BACKGROUND: Off-pump coronary artery bypass grafting (OPCAB) has been shown to be an effective strategy for surgical revascularization. The purpose of this study was to define the incidence of intraoperative conversion from OPCAB to on-pump coronary artery bypass grafting (ONCAB) and report outcomes based on the reason for conversion. METHODS: Starting in July 2007, the Society of Thoracic Surgeons database captured patients that were planned OPCAB but then were converted to ONCAB. A total of 196,576 patients undergoing planned OPCAB within the Society of Thoracic Surgeons National Database from July 2007 to June 2014 were evaluated. Patients were grouped according to their intraoperative conversion to cardiopulmonary bypass: (1) planned conversion, (2) unplanned conversion for visualization, (3) unplanned conversion for hemodynamic instability, and (4) no conversion (OPCAB). Multiple logistic regression analysis was used to determine risk factors for conversion. RESULTS: The overall rate of conversion from OPCAB to ONCAB was 5.5%, with 49.6% of the conversions being planned. When compared with those not undergoing conversion (OPCAB, 30-day mortality observed to expected ratio [O/E], 0.8), those undergoing conversion to ONCAB experienced greater 30-day mortality regardless of etiology of conversion (planned conversion O/E, 1.4; unplanned conversion for visualization O/E, 1.6; and unplanned conversion for hemodynamic instability O/E, 2.7). Similar O/E ratios were observed for renal failure and prolonged ventilation following conversion. Logistic regression analysis showed advanced age, ejection fraction less than 35%, preoperative intraaortic balloon pump placement, increasing number of diseased coronary arteries, preoperative heart failure within 2 weeks, and urgent procedural status were all independent predictors for conversion to ONCAB (p ≤ 0.01). CONCLUSIONS: Intraoperative conversion from OPCAB to ONCAB remains a morbid event with a risk of mortality much higher than expected. Surgeons should consider elective ONCAB in those with a high risk for conversion during OPCAB.

Acute Kidney Injury Severity and Long-Term Readmission and Mortality After Cardiac Surgery.

BACKGROUND: Acute kidney injury (AKI) is a common complication after cardiac surgery. While AKI severity is known to be associated with increased risk of short-term outcomes, its long-term impact is less well understood. METHODS: Adult patients undergoing isolated coronary artery bypass graft surgery at eight centers were enrolled into the Northern New England biomarker registry (n = 1,610). Patients were excluded if they had renal failure (n = 15) or died during index admission (n = 38). Severity of AKI was defined using the Acute Kidney Injury Network (AKIN). We linked our cohort to national Medicare and state all-payer claims to ascertain readmissions and to the National Death Index to ascertain survival. Kaplan-Meier and multivariate Cox proportional hazards modeling was conducted for time to readmission and death over 5 years. RESULTS: Within 5 years, 513 patients (33.8%) had AKI with AKIN stage 1 (29.9%) and stage 2 to 3 (3.9%). There were 620 readmissions (39.9%) and 370 deaths (23.8%). After adjustment, stage 1 AKI patients had a 31% increased risk of readmission (95% confidence interval [CI]: 1.10 to 1.57), whereas stage 2 or 3 patients had a 98% increased risk (95% CI: 1.41 to 2.78) compared with patients having no AKI. Relative to patients without AKI, stage 1 patients had a 56% increased risk of mortality (95% CI: 1.14 to 2.13), whereas stage 2 or 3 patients had a 3.5 times higher risk (95% CI: 2.16 to 5.60). CONCLUSIONS: Severity of AKI using the AKIN stage criteria is associated with a significantly increased risk of 5-year readmission and mortality. Our findings suggest that efforts to reduce AKI in the perioperative period may have a significant long-term impact on patients and payers in reducing mortality and health care utilization.

Building a laboratory workforce to meet the future: ASCP Task Force on the Laboratory Professionals Workforce.

OBJECTIVES: To analyze the demand for services from the nation's medical laboratories, which is predicted to dramatically increase as our citizens age and millions receive insurance coverage through the Affordable Care Act. METHODS: A systematic review of relevant publications and databases was conducted to assess the current state of the nation's medical laboratory workforce and to examine the impact of population demographics and health reform on workforce development to address the future demand for laboratory services. RESULTS: Building a Laboratory Workforce to Meet the Future, a new report from the American Society for Clinical Pathology (ASCP), provides a comprehensive strategy to address the future workforce needs of the nation's medical laboratories to meet this demand to provide timely, accurate, and safe patient care and to fully realize the benefits of personalized medicine. CONCLUSIONS: The report, from the ASCP Task Force on the Laboratory Professionals Workforce, is a comprehensive review of the myriad of factors affecting recruitment and retention of qualified laboratory professionals and provides a set of thoughtful recommendations outlining a multifaceted approach to bolster the pipeline of potential candidates for the profession as well as leadership in health care.

N-alkyl urea hydroxamic acids as a new class of peptide deformylase inhibitors with antibacterial activity.

Peptide deformylase (PDF) is a prokaryotic metalloenzyme that is essential for bacterial growth and is a new target for the development of antibacterial agents. All previously reported PDF inhibitors with sufficient antibacterial activity share the structural feature of a 2-substituted alkanoyl at the P(1)' site. Using a combination of iterative parallel synthesis and traditional medicinal chemistry, we have identified a new class of PDF inhibitors with N-alkyl urea at the P(1)' site. Compounds with MICs of 200 micro M for matrilysin and other mammalian metalloproteases. Structure-activity relationship analysis identified preferred substitutions resulting in improved potency and decreased cytotoxity. One of the compounds (VRC4307) was cocrystallized with PDF, and the enzyme-inhibitor structure was determined at a resolution of 1.7 A. This structural information indicated that the urea compounds adopt a binding position similar to that previously determined for succinate hydroxamates. Two compounds, VRC4232 and VRC4307, displayed in vivo efficacy in a mouse protection assay, with 50% protective doses of 30.8 and 17.9 mg/kg of body weight, respectively. These N-alkyl urea hydroxamic acids provide a starting point for identifying new PDF inhibitors that can serve as antimicrobial agents.