Electronic Health Record Functionality Needed to Better Support Primary Care

Electronic health records (EHRs) must support primary care clinicians and patients, yet many clinicians remain dissatisfied with their system. This manuscript presents a consensus statement about gaps in current EHR functionality and needed enhancements to support primary care. The Institute of Medicine primary care attributes were used to define needs and Meaningful Use (MU) objectives to define EHR functionality. Current objectives remain disease- rather than whole-person focused, ignoring factors like personal risks, behaviors, family structure, and occupational and environmental influences. Primary care needs EHRs to move beyond documentation to interpreting and tracking information over time as well as patient partnering activities, support for team based care, population management tools that deliver care, and reduced documentation burden. While Stage 3 MU’s focus on outcomes is laudable, enhanced functionality is still needed including EHR modifications, expanded use of patient portals, seamless integration with external applications, and advancement of national infrastructure and policies

Addressing marine and coastal governance conflicts at the interface of multiple sectors and jurisdictions

Marine and coastal activities are closely interrelated, and conflicts among different sectors can undermine management and conservation objectives. Governance systems for fisheries, power generation, irrigation, aquaculture, marine biodiversity conservation, and other coastal and maritime activities are typically organized to manage conflicts within sectors, rather than across them. Based on the discussions around eight case studies presented at a workshop held in Brest in June 2019, this paper explores institutional approaches to move beyond managing conflicts within a sector. We primarily focus on cases where the groups and sectors involved are heterogeneous in terms of: the jurisdiction they fall under; their objectives; and the way they value ecosystem services. The paper first presents a synthesis of frameworks for understanding and managing cross-sectoral governance conflicts, drawing from social and natural sciences. We highlight commonalities but also conceptual differences across disciplines to address these issues. We then propose a novel analytical framework which we used to evaluate the eight case studies. Based on the main lessons learned from case studies, we then discuss the feasibility and key determinants of stakeholder collaboration as well as compensation and incentive schemes. The discussion concludes with future research needs to support policy development and inform integrated institutional regimes that consider the diversity of stakeholder interests and the potential benefits of cross-sectoral coordination

The Public Health Exposome: A Population-Based, Exposure Science Approach to Health Disparities Research

The lack of progress in reducing health disparities suggests that new approaches are needed if we are to achieve meaningful, equitable, and lasting reductions. Current scientific paradigms do not adequately capture the complexity of the relationships between environment, personal health and population level disparities. The public health exposome is presented as a universal exposure tracking framework for integrating complex relationships between exogenous and endogenous exposures across the lifespan from conception to death. It uses a social-ecological framework that builds on the exposome paradigm for conceptualizing how exogenous exposures “get under the skin”. The public health exposome approach has led our team to develop a taxonomy and bioinformatics infrastructure to integrate health outcomes data with thousands of sources of exogenous exposure, organized in four broad domains: natural, built, social, and policy environments. With the input of a transdisciplinary team, we have borrowed and applied the methods, tools and terms from various disciplines to measure the effects of environmental exposures on personal and population health outcomes and disparities, many of which may not manifest until many years later. As is customary with a paradigm shift, this approach has far reaching implications for research methods and design, analytics, community engagement strategies, and research training

Data Publication with the Structural Biology Data Grid Supports Live Analysis

Access to experimental X-ray diffraction image data is fundamental for validation and reproduction of macromolecular models and indispensable for development of structural biology processing methods. Here, we established a diffraction data publication and dissemination system, Structural Biology Data Grid (SBDG; data.sbgrid.org), to preserve primary experimental data sets that support scientific publications. Data sets are accessible to researchers through a community driven data grid, which facilitates global data access. Our analysis of a pilot collection of crystallographic data sets demonstrates that the information archived by SBDG is sufficient to reprocess data to statistics that meet or exceed the quality of the original published structures. SBDG has extended its services to the entire community and is used to develop support for other types of biomedical data sets. It is anticipated that access to the experimental data sets will enhance the paradigm shift in the community towards a much more dynamic body of continuously improving data analysis

Toward a 21st-century health care system: Recommendations for health care reform

The coverage, cost, and quality problems of the U.S. health care system are evident. Sustainable health care reform must go beyond financing expanded access to care to substantially changing the organization and delivery of care. The FRESH-Thinking Project (www.fresh-thinking.org) held a series of workshops during which physicians, health policy experts, health insurance executives, business leaders, hospital administrators, economists, and others who represent diverse perspectives came together. This group agreed that the following 8 recommendations are fundamental to successful reform: 1. Replace the current fee-for-service payment system with a payment system that encourages and rewards innovation in the efficient delivery of quality care. The new payment system should invest in the development of outcome measures to guide payment. 2. Establish a securely funded, independent agency to sponsor and evaluate research on the comparative effectiveness of drugs, devices, and other medical interventions. 3. Simplify and rationalize federal and state laws and regulations to facilitate organizational innovation, support care coordination, and streamline financial and administrative functions. 4. Develop a health information technology infrastructure with national standards of interoperability to promote data exchange. 5. Create a national health database with the participation of all payers, delivery systems, and others who own health care data. Agree on methods to make de-identified information from this database on clinical interventions, patient outcomes, and costs available to researchers. 6. Identify revenue sources, including a cap on the tax exclusion of employer-based health insurance, to subsidize health care coverage with the goal of insuring all Americans. 7. Create state or regional insurance exchanges to pool risk, so that Americans without access to employer-based or other group insurance could obtain a standard benefits package through these exchanges. Employers should also be allowed to participate in these exchanges for their employees' coverage. 8. Create a health coverage board with broad stakeholder representation to determine and periodically update the affordable standard benefit package available through state or regional insurance exchanges

Electronic and protein structural dynamics of a photosensory histidine kinase

The bacterium Caulobucter crescent us encodes a two-component signaling protein, LovK, that contains an N-terminal photosensory LOV domain coupled to a C-terminal histidine kinase. LovK binds a flavin cofactor, undergoes a reversible photocycle, and displays regulated ATPase and autophosphorylation activity in response to visible light. Femtosecond to nanosecond visible absorption spectroscopy demonstrates congruence between full-length LovK and isolated LOV domains in the mechanism and kinetics of light-dependent cysteinyl-C4(a) adduct formation and rupture, while steady-state absorption and fluorescence line narrowing (FLN) spectroscopies reveal unique features in the electronic structure of the LovK flavin cofactor. In agreement with other sensor histidine kinases, ATP binds specifically to LovK with micromolar affinity. However, ATP binding to the histidine kinase domain of LovK has no apparent effect on global protein structure as assessed by differential Fourier transform infrared (FTIR) spectroscopy. Cysteinyl adduct formation results in only minor changes in the structure of LovK as determined by differential FTIR. This study provides insight into the structural underpinnings of LOV-mediated signal transduction in the context of a full-length histidine kinase. In particular, the data provide evidence for a model in which small changes in the tertiary/quaternary structure of LovK, as triggered by photon detection in the N-terminal LOV sensory domain, are sufficient to regulate histidine kinase activity

Comparison of Methods for Identifying Resistant Herpes Simplex Virus and Measuring Antiviral Susceptibility

Background: A number of in vitro assays are used to determine susceptibility of HSV to antiviral agents, but results from these in vitro assays do not necessarily correlate with treatment outcome. Objectives: A method with improved capability for identifying an isolate as acyclovir (ACV) or penciclovir (PCV) resistant when resistance is borderline could greatly improve the management of HSV disease. Study design: A comparative evaluation of four in vitro assays, plaque reduction (PRA), DNA hybridization, plating efficiency (PEA) and plaque autoradiography (PAR) was performed to accurately identify and measure resistance of a TK-altered clinical HSV isolate (HSV-1 N4) from a patient who was non-responsive to ACV treatment. Two established criteria for the prediction of antiviral resistance, IC 50≥2.0 μg/ml or an IC 50 greater than 10× above a sensitive virus IC 50, as well as testing in human (MRC-5) and nonhuman (Vero and CV-1 monkey kidney) cell lines were evaluated. Results: The PRA and DNA hybridization assays accurately identified HSV-1 N4 as ACV r in human cells when using the 10× above sensitive virus IC 50 resistance criterion. Moreover, the PEA and PAR assays failed to classify HSV-1 N4 as drug resistant and indicate that these technologies alone are inadequate for identifying resistant virus. Conclusions: The data presented herein indicate that the PRA and DNA hybridization assays most accurately identified an otherwise borderline-resistant isolate as drug resistant: (i) when a sensitive virus is used within each individual assay as a control, (ii) when ACV and PCV susceptibility is evaluated in human cells, and (iii) when the 10× above sensitive IC 50 criterion is used to classify a virus as drug-resistant. Testing of additional clinical samples is warranted to further confirm these findings. © 2002 Elsevier Science B.V. All rights reserved.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Local Source Vp and Vs Tomography in the Mount St. Helens Region With the iMUSH Broadband Array

We present new 3-D P wave and S wave velocity models of the upper 20 km of the Mount St. Helens (MSH) region. These were obtained using local-source arrival time tomography from earthquakes and explosions recorded at 70 broadband stations deployed as part of the imaging Magma Under St. Helens (iMUSH) project and augmented by several data sets. Principal features of our models include (1) low P wave and S wave velocities along the St. Helens seismic zone to depths of at least 20 km corresponding to high conductivity imaged by iMUSH magnetotelluric studies. This delineates a zone of weakness that magma can exploit at the location of MSH; (2) a 5- to 7-km diameter, 6-15 km deep, 3-6% negative P wave and S wave velocity anomaly beneath MSH, consistent with previous estimates of the source region for recent eruptions. We interpret this as a magma storage region containing up to 15-20 km(3) of partial melt, which is about 5 times more than the largest documented eruption at MSH; (3) a broad region of low P wave velocity below 10-km depth extending between Mount Adams and Mount Rainier along and to the east of the main Cascade arc, which is likely due to high-temperature arc crust and possible presence of fluids or melt; (4) several anomalies associated with surface-mapped features, including high-velocity igneous units such as the Spud Mountain and Spirit Lake plutons and low velocities in the Chehalis sedimentary basin and the Indian Heaven volcanic field. Our results place further constraints on the geometry of these features at depth. Plain Language Summary We deployed 70 seismometers around Mount St. Helens volcano from 2014 to 2016, which measured the surface ground motion from hundreds of small earthquakes, as well as from 23 explosions that were set off in 2014. We recorded the onset time of shaking from these sources and used a specialized computer code to model how quickly seismic waves travel through the subsurface. Seismic wave speed can be influenced by several factors, including rock type, presence of magma/fluids, temperature, pressure, and how fractured the rock is. Based on the seismic wave speeds in our model, we make several geological interpretations, including (1) increased fluids or fractures, or presence of sedimentary rocks corresponding to elevated earthquake activity to the NNW of Mount St. Helens; (2) a magma storage region beneath the volcano similar to results from previous studies. Our model places further constraints on the orientation and size of the region; (3) a large zone of high temperatures and possible fluids or magma related to regional volcanism between and to the east of Mount Adams and Mount Rainier; (4) more detailed size and depth constraints on geological features seen at the surface, including sedimentary basins and rock units related to previous regional volcanism. Key Points New high-resolution P wave and S wave velocity models are calculated for the Mount St. Helens region Velocity models place further constraints on size and location of magma storage regions, seismic zones, sedimentary basins, and plutons These shed light on the accretionary history of the Siletzia terrane, with a transitional upper crustal boundary near Mount St. HelensNational Science Foundation of Sri Lanka6 month embargo; first published online 19 February 2020This item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]