Electronic health information exchange in underserved settings: examining initiatives in small physician practices & community health centers.

BackgroundHealth information exchange (HIE) is an important tool for improving efficiency and quality and is required for providers to meet Meaningful Use certification from the United States Centers for Medicare and Medicaid Services. However widespread adoption and use of HIE has been difficult to achieve, especially in settings such as smaller-sized physician practices and federally qualified health centers (FQHCs). We assess electronic data exchange activities and identify barriers and benefits to HIE participation in two underserved settings.MethodsWe conducted key-informant interviews with stakeholders at physician practices and health centers. Interviews were recorded, transcribed, and then coded in two waves: first using an open-coding approach and second using selective coding to identify themes that emerged across interviews, including barriers and facilitators to HIE adoption and use.ResultsWe interviewed 24 providers, administrators and office staff from 16 locations in two states. They identified barriers to HIE use at three levels-regional (e.g., lack of area-level exchanges; partner organizations), inter-organizational (e.g., strong relationships with exchange partners; achieving a critical mass of users), and intra-organizational (e.g., type of electronic medical record used; integration into organization's workflow). A major perceived benefit of HIE use was the improved care-coordination clinicians could provide to patients as a direct result of the HIE information. Utilization and perceived benefit of the exchange systems differed based on several practice- and clinic-level factors.ConclusionsThe adoption and use of HIE in underserved settings appears to be impeded by regional, inter-organizational, and intra-organizational factors and facilitated by perceived benefits largely at the intra-organizational level. Stakeholders should consider factors both internal and external to their organization, focusing efforts in changing modifiable factors and tailoring HIE efforts based on all three categories of factors. Collective action between organizations may be needed to address inter-organizational and regional barriers. In the interest of facilitating HIE adoption and use, the impact of interventions at various levels on improving the use of electronic health data exchange should be tested

Use of in vitro and haptic assessments in the characterisation of surface lubricity

Lubricity is a key property of hydrophilic-coated urinary catheter surfaces. In vitro tests are commonly employed for evaluation of surface properties in the development of novel catheter coating technologies, however, their value in predicting the more subjective feeling of lubricity requires validation. We herein perform a range of in vitro assessments and human organoleptic studies to characterise surface properties of developmental hydrophilic coating formulations, including water wettability, coefficient of friction, dry-out kinetics and lubricity. Significant reductions of up to 40% in the contact angles and coefficient of friction values of the novel coating formulations in comparison to the control poly(vinyl pyrrolidone)-coated surfaces were demonstrated during quantitative laboratory assessments. In contrast, no significant differences in the more subjective feeling of lubricity between the novel formulations and the control-coated surfaces were observed when formulations were haptically assessed by the techniques described herein. This study, importantly, highlights the need for optimisation of in vitro and human haptic assessments to more reliably predict patient preferences

The Multitude of Molecular Hydrogen Knots in the Helix Nebula

We present HST/NICMOS imaging of the H_2 2.12 \mu m emission in 5 fields in the Helix Nebula ranging in radial distance from 250-450" from the central star. The images reveal arcuate structures with their apexes pointing towards the central star. Comparison of these images with comparable resolution ground based images reveals that the molecular gas is more highly clumped than the ionized gas line tracers. From our images, we determine an average number density of knots in the molecular gas ranging from 162 knots/arcmin^2 in the denser regions to 18 knots/arcmin^2 in the lower density outer regions. Using this new number density, we estimate that the total number of knots in the Helix to be ~23,000 which is a factor of 6.5 larger than previous estimates. The total neutral gas mass in the Helix is 0.35 M_\odot assuming a mass of \~1.5x10^{-5} M_\odot for the individual knots. The H_2 intensity, 5-9x10^{-5} erg s^{-1} cm^{-2} sr^{-1}, remains relatively constant with projected distance from the central star suggesting a heating mechanism for the molecular gas that is distributed almost uniformly in the knots throughout the nebula. The temperature and H_2 2.12 \mu m intensity of the knots can be approximately explained by photodissociation regions (PDRs) in the individual knots; however, theoretical PDR models of PN under-predict the intensities of some knots by a factor of 10.Comment: 26 pages, 3 tables, 10 figures; AJ accepte

Unraveling the Helix Nebula: Its Structure and Knots

Through HST imaging of the inner part of the main-ring of the Helix Nebula together with CTIO 4-m images of the fainter outer parts, we have an unprecedented-quality view of the nearest bright planetary nebula. These images have allowed determination that the main-ring of the nebula is composed of an inner-disk of about 499\arcsec diameter (0.52 pc) surrounded by an outer-ring (in reality a torus) of 742\arcsec diameter (0.77 pc) whose plane is highly inclined to the plane of the disk. This outer-ring is surrounded by an outermost-ring of 1500\arcsec (1.76 pc) diameter which is flattened on the side colliding with the ambient interstellar medium. The inner-disk has an extended distribution of low density gas along its rotational axis of symmetry and the disk is optically thick to ionizing radiation, as is the outer-ring. Published radial velocities of the knots provides support for the two-component structure of the main-ring of the nebula and to the idea that the knots found there are expanding along with the nebular material from which it recently originated. There is a change in the morphology of the knots as a function of the distance from the local ionization front. This supports a scenario in which the knots are formed in or near the ionization front and are then sculpted by the stellar radiation from the central star as the ionization front advances beyond them.Comment: 30 pages, 20 figures, many figures have reduce fidelity for astroph preprint. Note: URLs in preprint were change

High fidelity blood flow in a patient-specific arteriovenous fistula

An arteriovenous fistula, created by artificially connecting segments of a patient's vasculature, is the preferred way to gain access to the bloodstream for kidney dialysis. The increasing power and availability of supercomputing infrastructure means that it is becoming more realistic to use simulations to help identify the best type and location of a fistula for a specific patient. We describe a 3D fistula model that uses the lattice Boltzmann method to simultaneously resolve blood flow in patient-specific arteries and veins. The simulations conducted here, comprising vasculatures of the whole forearm, demonstrate qualified validation against clinical data. Ongoing research to further encompass complex biophysics on realistic time scales will permit the use of human-scale physiological models for basic and clinical medicine

Effects of Wearing an ACL Brace on Hamstring and Quadriceps Muscle Activity When Performing a Body Weight Squat

After surgical repair of the anterior cruciate ligament (ACL) a functional knee brace is used to support the injured knee. Of importance, would be the reduction of actions that would promote anterior tibial translation relative to the femur. PURPOSE: The purpose of this study was to determine if the use of a functional ACL brace proportionally reduces quadriceps relative to hamstring muscle activity during a body weight squat. METHODS: Seven collegiate athletes (20.5±1.0 yrs, 183.9±9.58 cm and 91.77±11.95 kg) provided informed consent and participated in this study. Two gel bipolar surface Ag-AgCl electrodes were placed on each of the muscle bellies of the vastus lateralis (VL) and the biceps femoris (BF) of the dominant leg. Participants performed eight repetitions of a two-legged bodyweight squat with and without a functional knee brace at a cadence of 54 bpm. RMS EMG was computed across a 200 ms window and analyzed for the middle six repetitions at 45° and 60° of knee flexion during the movement. EMG data were collected at 1000Hz and normalized to the respective maximum voluntary isometric contraction (MVIC) for each muscle. Hamstrings and quadriceps activity for the upward phase of movement were evaluated separately, with two 2x2 (Muscle x Brace Condition) repeated measures ANOVAs. RESULTS: No interaction between muscle and brace condition was observed at 45° (F(1,6) = 5.369, p = 0.06) or 60° (F(1,6) = 5.241 p = 0.062). At 45° and 60° quadriceps activity tended to increase and hamstrings activity tended to decrease when wearing the brace (Table 1) but these differences were not significant (F(1,6)=2.54, p=0.16; F(1,6)=2.90, p=0.14, respectively). CONCLUSION: The trend in muscle activity surprisingly suggests that the movement was more quadriceps dominant while wearing the brace. The quadriceps group had 4.6x and 1.7x more muscle activity than the hamstring during the braced squat and non-braced squat respectively. This data suggests that after the initial healing period, when rehabilitating an ACL injury the functional brace should be used sparingly so the hamstrings may be adequately strengthened

Failure of vaccination to prevent outbreaks of foot-and-mouth disease

Outbreaks of foot-and-mouth disease persist in dairy cattle herds in Saudi Arabia despite revaccination at intervals of 4-6 months. Vaccine trials provide data on antibody responses following vaccination. Using this information we developed a mathematical model of the decay of protective antibodies with which we estimated the fraction of susceptible animals at a given time after vaccination. The model describes the data well, suggesting over 95% take with an antibody half-life of 43 days. Farm records provided data on the time course of five outbreaks. We applied a 'SLIR' epidemiological model to these data, fitting a single parameter representing disease transmission rate. The analysis provides estimates of the basic reproduction number R(0), which may exceed 70 in some cases. We conclude that the critical intervaccination interval which would provide herd immunity against FMDV is unrealistically short, especially for heterologous challenge. We suggest that it may not be possible to prevent foot-and-mouth disease outbreaks on these farms using currently available vaccines