Information in Healthcare: An Ethnographic Analysis of a Hospital Ward.

This dissertation uses psychosocial information as a lens to examine doctors’ and nurses’ information use and documentation practice. It draws on a 17-month ethnographic study, in-depth analysis of medical records, and semi-structured interviews to investigate clinicians’ documentation behaviors. This investigation produced several findings. First, adopting a Computerized Prescriber Order Entry (CPOE) system can cause loss of written psychosocial information as nurses reluctantly make certain data permanent. Second, CPOE adoption may create information gaps in nurses’ knowledge about patients. Third, while use of CPOE systems can successfully reduce medication errors, it removes discretion, nuance, temporality, and human interpretation from paper order practice to rigidly fit machine requirements. This can redistribute power and responsibility. Fourth, although doctors document psychosocial information in an electronic health records (EHR) system, they record it selectively and a medicalized viewpoint governs this selection process. As a result, missing patient representations affect work activities and patient care. This study has broad implications for medical informatics. It cautions against casual computerization. Many well-intentioned efforts to computerize paper records assume the transition only changes media, but this study shows how social agreement and institutional arrangement around documenting patient psychosocial information can be shattered by this transition. It also suggests that efforts should be made to respect local knowledge and practice in the computerization of medical information. The findings also suggest a need for a dual conceptualization of EHR as both a representation of medical work (process-oriented) and patients (patient-centered, as to consider information reuse from a long-term perspective). This study also seeks to extend theories of boundary objects. It reveals that the nature of a boundary object can change when that object and the practice surrounding its use are both automated. It proposes to conceptualize process-oriented systems, such as CPOE or EHR, as information assemblages, which embed multiple information objects, heterogeneous practices, work processes, and coordination mechanisms. Furthermore, the analysis of this study uses a stack of conceptual framings: boundary object, extended boundary object, assembled object, collection, and assemblage, and argues these framings together serve to understand computerized records in a medical setting far better than can any single concept.Ph.D.InformationUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/78940/1/xmzhou_1.pd

Understanding patient-provider communication entered via a patient portal system

ABSTRACT Our study examines patient-provider communication via a patient portal in a large medical center. Our study is based on 1172 interactions made among stakeholders concerning 100 patients who are randomly selected from the 2009 MyHealthAtVanderbilt.com (a patient portal at the Vanderbilt Medical Center) patient pool; among which, 35 use the patient portal for messages. The findings show a wide range of topics discussed and ways in which patients provide and seek information as well as express psychosocial and emotional needs. In addition, while the patient portal has advantages over traditional communication technologies, it was not the primary communication media for our study sample. More research is needed to better elucidate barriers to the use of patient portals and the optimal methods of communication in differing contexts

Human-centered design and evaluation of AI-empowered clinical decision support systems: a systematic review

IntroductionArtificial intelligence (AI) technologies are increasingly applied to empower clinical decision support systems (CDSS), providing patient-specific recommendations to improve clinical work. Equally important to technical advancement is human, social, and contextual factors that impact the successful implementation and user adoption of AI-empowered CDSS (AI-CDSS). With the growing interest in human-centered design and evaluation of such tools, it is critical to synthesize the knowledge and experiences reported in prior work and shed light on future work.MethodsFollowing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic review to gain an in-depth understanding of how AI-empowered CDSS was used, designed, and evaluated, and how clinician users perceived such systems. We performed literature search in five databases for articles published between the years 2011 and 2022. A total of 19874 articles were retrieved and screened, with 20 articles included for in-depth analysis.ResultsThe reviewed studies assessed different aspects of AI-CDSS, including effectiveness (e.g., improved patient evaluation and work efficiency), user needs (e.g., informational and technological needs), user experience (e.g., satisfaction, trust, usability, workload, and understandability), and other dimensions (e.g., the impact of AI-CDSS on workflow and patient-provider relationship). Despite the promising nature of AI-CDSS, our findings highlighted six major challenges of implementing such systems, including technical limitation, workflow misalignment, attitudinal barriers, informational barriers, usability issues, and environmental barriers. These sociotechnical challenges prevent the effective use of AI-based CDSS interventions in clinical settings.DiscussionOur study highlights the paucity of studies examining the user needs, perceptions, and experiences of AI-CDSS. Based on the findings, we discuss design implications and future research directions

31st Annual Meeting and Associated Programs of the Society for Immunotherapy of Cancer (SITC 2016) : part two

Background The immunological escape of tumors represents one of the main ob- stacles to the treatment of malignancies. The blockade of PD-1 or CTLA-4 receptors represented a milestone in the history of immunotherapy. However, immune checkpoint inhibitors seem to be effective in specific cohorts of patients. It has been proposed that their efficacy relies on the presence of an immunological response. Thus, we hypothesized that disruption of the PD-L1/PD-1 axis would synergize with our oncolytic vaccine platform PeptiCRAd. Methods We used murine B16OVA in vivo tumor models and flow cytometry analysis to investigate the immunological background. Results First, we found that high-burden B16OVA tumors were refractory to combination immunotherapy. However, with a more aggressive schedule, tumors with a lower burden were more susceptible to the combination of PeptiCRAd and PD-L1 blockade. The therapy signifi- cantly increased the median survival of mice (Fig. 7). Interestingly, the reduced growth of contralaterally injected B16F10 cells sug- gested the presence of a long lasting immunological memory also against non-targeted antigens. Concerning the functional state of tumor infiltrating lymphocytes (TILs), we found that all the immune therapies would enhance the percentage of activated (PD-1pos TIM- 3neg) T lymphocytes and reduce the amount of exhausted (PD-1pos TIM-3pos) cells compared to placebo. As expected, we found that PeptiCRAd monotherapy could increase the number of antigen spe- cific CD8+ T cells compared to other treatments. However, only the combination with PD-L1 blockade could significantly increase the ra- tio between activated and exhausted pentamer positive cells (p= 0.0058), suggesting that by disrupting the PD-1/PD-L1 axis we could decrease the amount of dysfunctional antigen specific T cells. We ob- served that the anatomical location deeply influenced the state of CD4+ and CD8+ T lymphocytes. In fact, TIM-3 expression was in- creased by 2 fold on TILs compared to splenic and lymphoid T cells. In the CD8+ compartment, the expression of PD-1 on the surface seemed to be restricted to the tumor micro-environment, while CD4 + T cells had a high expression of PD-1 also in lymphoid organs. Interestingly, we found that the levels of PD-1 were significantly higher on CD8+ T cells than on CD4+ T cells into the tumor micro- environment (p < 0.0001). Conclusions In conclusion, we demonstrated that the efficacy of immune check- point inhibitors might be strongly enhanced by their combination with cancer vaccines. PeptiCRAd was able to increase the number of antigen-specific T cells and PD-L1 blockade prevented their exhaus- tion, resulting in long-lasting immunological memory and increased median survival

Patient-provider communication and information access via online patient portal: Understanding user behaviors to improve healthcare and outcomes

Patient-physician communication is moving online. While face-to-face communication remains critical, information technologies (e.g. SMS, email, e-visit system) have been used to serve additional communication channels between patients and providers beyond clinical encounters. Our study investigated a patient portal system implemented in a large medical center. We employed both quantitative and qualitative methods to analyze 1172 interactions via the portal among patients, physicians, nurses and secretaries. Our analysis revealed rich accounts about the topics patients communicated with their providers and how patients discussed sensitive issues regarding their routine illness management. This helped their providers understand patients better not only in their medical situation but also how patients coped with chronic diseases in their larger social context. Furthermore, this study explores how information technologies can be better designed to empower patient-provider communication, facilitate information delivery, and enable patients and general populations to take an active role in their routine healthcare management.published or submitted for publicationis peer reviewe

Development of microsatellite markers and genetic diversity in wild and cultured populations of black carp (Mylopharyngodon piceus) along the Yangtze River

Black carp (Mylopharyngodon piceus) is one of traditionally important aquaculture fishes in China; however, population genetic studies are relatively rare for this species. In the present study, we developed a set of microsatellite markers by FIASCO method and used ten of these polymorphic markers to evaluate genetic diversity of black carp (three wild populations and six cultured populations including larvae from fish seed farms and adults from fish markets,n = 269) along the Yangtze River basin. Among these samples, mean number of alleles (Na) and effective number of alleles (Ne) were 14 and 6, respectively. Genetic diversities of wild populations were higher than that of cultured populations, represented byHoof 0.767 vs 0.730,Heof 0.806 vs 0.722, andpolymorphism information contentof 0.767 vs 0.6731, respectively, although a few cultured populations were exceptional.Fst from 0.010 to 0.159 showed a moderate level of population differentiations, and Bayesian and clustering analysis consistently supported that these populations could be divided into 7 clusters. This study generated novel microsatellites and new evidence of genetic differentiation between wild and cultured populations of black carp, which are useful for conservation and sustainable utilization of fishery resources

Brain and intestine transcriptome analyses and identification of genes involved in feed conversion efficiency of Yellow River carp (Cyprinus carpio haematopterus)

Feed cost is one of the largest variable input costs in aquaculture. In general, dietary energy is directed toward protein deposition and muscle growth. However, most of the dietary energy will be used to support body maintenance if feed conversion efficiency (FCE) is relatively low. Thus, improving feed efficiency will make great contributions to the productivity, profitability, and sustainability of fish farming industry. In the present study, we performed comparative transcriptome analyses of brain and intestine tissues from extreme FCE groups and identified differentially expressed genes (DEGs) and regulatory pathways that may be involved in FCE and related traits in one of the important common carp strains of China, the Yellow River carp (Cyprinus carpio haematopterus). Totally, 557 and 341 DEGs between high and low FCE groups were found in brain and intestine tissues, respectively, including 66 up- and 491 down-regulated in brain of high FCE group and 282 up- and 59 down-regulated in intestine of high FCE group (p < 0.01, FDR < 0.05). These DEGs are mainly involved in metabolic pathway, organismal system and genetic information processing pathway. Finally, 20 key DEGs potentially involved in FCE of Yellow River carp were identified from these two tissues. Expression patterns (up or down regulation in the high or low FCE group) of these DEGs have been successfully validated by quantitative real-time PCR of 10 unigenes. This study provides insights into the genetic mechanisms underlying feed efficiency in Yellow River carp and supplies valuable FCE-related candidate gene resources for potential molecular breeding studies