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Chart review is central to understanding adverse events (AEs) in medicine. In this article, we describe the process and results of educating chart reviewers assigned to evaluate dental AEs.We developed a Web-based training program, "Dental Patient Safety Training," which uses both independent and consensus-based curricula, for identifying AEs recorded in electronic health records in the dental setting. Training included (1) didactic education, (2) skills training using videos and guided walkthroughs, (3) quizzes with feedback, and (4) hands-on learning exercises. In addition, novice reviewers were coached weekly during consensus review discussions. TeamExpert was composed of 2 experienced reviewers, and TeamNovice included 2 chart reviewers in training. McNemar test, interrater reliability, sensitivity, specificity, positive predictive value, and negative predictive value were calculated to compare accuracy rates on the identification of charts containing AEs at the start of training and 7 months after consensus building discussions between the 2 teams.TeamNovice completed independent and consensus development training. Initial chart reviews were conducted on a shared set of charts (n = 51) followed by additional training including consensus building discussions. There was a marked improvement in overall percent agreement, prevalence and bias-adjusted κ correlation, and diagnostic measures (sensitivity, specificity, positive predictive value, and negative predictive value) of reviewed charts between both teams from the phase I training program to phase II consensus building.This study detailed the process of training new chart reviewers and evaluating their performance. Our results suggest that standardized training and continuous coaching improves calibration between experts and trained chart reviewers.

BACKGROUND Peripartum Depression (PPD) affects approximately 1 in 10 pregnant women and 1 in 8 new mothers in the U.S. every year, representing a significant population. Women of low socioeconomic status (low-SES) are more likely to develop PPD symptoms. Multilevel treatment barriers including, but not limited to, social stigma, misguided expectations on the role of motherhood, and not having appropriate PPD knowledge or access to mental health resources have played a major role in PPD-related disparities. Emerging advances in digital technologies and analytics provide us with opportunities to address access barriers, knowledge gaps, and engagement issues. However, the majority of digital market solutions currently available are produced in a generic manner and do not consider the information and technology needs of low-SES populations. OBJECTIVE In this research study, we describe our qualitative approach towards evaluating low-SES women and providers’ current experiences with digital management of perinatal mental health, and supplement this with information gathered from participants in PPD-related online forums. METHODS We have conducted (a) 2 focus groups (n= 9), (b) semi-structured interviews with care providers (n= 9) and low SES women (n= 10), as well as (c) secondary analysis of online forum messages (n= 1,424). Qualitative data were inductively analyzed using grounded theory, where we first perform line-by-line open coding of the data and then discover key PPD information and technology user needs through identifying patterns and relationships among core concepts. RESULTS Our qualitative analysis resulted in a total of 134 open codes from patient interviews, 185 from provider interviews, and 106 from focus groups. These revealed six core themes for PPD management: 1) “Use of Technology/Features”, 2) “Access to Care”, 3) “Pregnancy Education”, 4) “Social and Community Support”, 5) “Sources of information”, and 6) “Digital Data”. Two themes that were uniquely brought up by providers were “Managerial and Administrative Support for Providers” and “Peripartum Depression Clinical Decision Support”. Our social media analysis revealed the following six PPD topics of importance in online messages: “Physical and Mental Health” (50.9% of messages), “Social Support” (47.3%), “Medications” (42.9%), “Mother and Infant Dyad” (32.3%), “Family and Friends” (30.1%), and “Doctor and Patient Dyad” (29.7%). CONCLUSIONS Our triangulation of data allowed us to analyze PPD information and technology needs at different levels of granularity. Differences between patient and provider included a focus from providers on needing better support from administrative staff, as well as better PPD clinical decision support. Our social media analysis provided us with insights into PPD topics of interest being discussed by a broader sample of women participating in an online community. Our results can inform future research and development efforts to address PPD health disparities among low-SES perinatal women.

Postpartum Depression (PPD) is the most common childbirth complication, with approximately 15% of postpartum women experiencing depression symptoms. Mobile applications have potential to expand delivery of mental health interventions. However, our understanding of how these tools engage women with PPD and facilitate positive behavioral changes is limited. In our paper, we analyze 15 commercial PPD applications to understand their role as facilitators of change, engagement, and sustained use. Applications reviewed contained an average of four theory-based behavioral change techniques, and highest patient engagement level reached was to empower patients through patient-generated data. Heuristic violations were identified in areas including user control and freedom, aesthetic and minimalist design, and help and documentation. An inverse correlation was found between the number of theory-based behavior change features and patient engagement. Findings suggest underserved populations may suffer further limitations accessing relevant health resources in the current application market.

Postpartum Depression (PPD) is the most common childbirth complication, with approximately 15% of postpartum women experiencing depression symptoms. Mobile applications have potential to expand delivery of mental health interventions. However, our understanding of how these tools engage women with PPD and facilitate positive behavioral changes is limited. In our paper, we analyze 15 commercial PPD applications to understand their role as facilitators of change, engagement, and sustained use. Applications reviewed contained an average of four theory-based behavioral change techniques, and highest patient engagement level reached was to empower patients through patient-generated data. Heuristic violations were identified in areas including user control and freedom, aesthetic and minimalist design, and help and documentation. An inverse correlation was found between the number of theory-based behavior change features and patient engagement. Findings suggest underserved populations may suffer further limitations accessing relevant health resources in the current application market.

Contact tracing is an essential public health tool for controlling epidemic disease outbreaks such as the COVID-19 pandemic. Digital contact tracing using real-time locations or proximity of individuals can be used to significantly speed up and scale up contact tracing. In this article, we present our project, REACT, for REAal-time Contact Tracing and risk monitoring via privacy-enhanced tracking of users' locations and symptoms. With privacy enhancement that allows users to control and refine the precision with which their information will be collected and used, REACT will enable: 1) contact tracing of individuals who are exposed to infected cases and identification of hot-spot locations, 2) individual risk monitoring based on the locations they visit and their contact with others; and 3) community risk monitoring and detection of early signals of community spread. We will briefly describe our ongoing work and the approaches we are taking as well as some challenges we encountered in deploying the app.

PURPOSE The evaluation of the effectiveness of simulation training in dentistry has previously been focused primarily on psychomotor hand skills. This study explored the impact of simulated patient (SP) encounters in simulation on students' self-assessment of competency in their clinical and communication abilities with geriatric patients. METHODS Students from 2 cohorts were recruited for this study. Cohort 1 (n = 30) participated in the standard curriculum with no simulation training and served as the control group. Cohort 2 (n = 34) participated in a SP experience, simulating the initial stages of a care visit for 2 nursing home patients. Students' perceptions of competency to perform these clinical and communication tasks were assessed. A group debriefing session was held 5 weeks post-simulation where Cohort 2 completed a student feedback form. RESULTS A statistically significant change (P

BACKGROUND Online health communities (OHCs) have emerged as the leading venues for behavior change and health-related information seeking. The soul and success of these digital platforms lie in their ability to foster social togetherness and a sense of community by providing personalized support. However, we have a minimal understanding of how conversational posts in these settings lead to collaborative societies and ultimately result in positive health changes through social influence. OBJECTIVE Our objective is to develop a content-specific and intent-sensitive methodological framework for analyzing peer interactions in OHCs. METHODS We developed and applied a mixed-methods approach to understand the manifestation of expressions in peer interactions in OHCs. We applied our approach to describe online social dialogue in the context of two online communities, QuitNet (QN) and the American Diabetes Association (ADA) support community. A total of 3011 randomly selected peer interactions (n=2005 from QN, n=1006 from ADA) were analyzed. Specifically, we conducted thematic analysis to characterize communication content and linguistic expressions (speech acts) embedded within the two data sets. We also developed an empirical user persona based on their engagement levels and behavior profiles. Further, we examined the association between speech acts and communication themes across observed tiers of user engagement and self-reported behavior profiles using the chi-square test or the Fisher test. RESULTS Although social support, the most prevalent communication theme in both communities, was expressed in several subtle manners, the prevalence of emotions was higher in the tobacco cessation community and assertions were higher in the diabetes self-management (DSM) community. Specific communication theme-speech act relationships were revealed, such as the social support theme was significantly associated (PPP CONCLUSIONS Such an overlay of communication intent implicit in online peer interactions alongside content-specific theory-linked characterizations of social media discourse can inform the development of effective digital health technologies in the field of health promotion and behavior change. Our analysis revealed a rich gradient of expressions across a standardized thematic vocabulary, with a distinct variation in emotional and informational needs, depending on the behavioral and disease management profiles within and across the communities. This signifies the need and opportunities for coupling pragmatic messaging in digital therapeutics and care management pathways for personalized support.

Digital technologies offer many opportunities to improve mental healthcare management for women seeking pre- and-postnatal care. They provide a discrete, practical medium that is well-suited for the sensitive nature of mental health. Women who are more prone to experiencing peripartum depression (PPD), such as those of low-socioeconomic background or in high-risk pregnancies, can benefit the most from such technologies. However, current digital interventions directed towards this population provide suboptimal support, and their responsiveness to end user needs is quite limited. Our objective is to understand the digital terrain of information needs for low-socioeconomic status women with high-risk pregnancies, specifically within the management of their mental health. This qualitative study consists of semi-structured focus groups and interviews with a sample of nineteen patients. A total of eleven core themes emerged from participant comments. Resulting themes highlighted the need for digital technologies that promote personalized care, a sense of community, and improved provider communication.

Digital technologies offer many opportunities to improve mental healthcare management for women seeking pre- and-postnatal care. They provide a discrete, practical medium that is well-suited for the sensitive nature of mental health. Women who are more prone to experiencing peripartum depression (PPD), such as those of low-socioeconomic background or in high-risk pregnancies, can benefit the most from such technologies. However, current digital interventions directed towards this population provide suboptimal support, and their responsiveness to end user needs is quite limited. Our objective is to understand the digital terrain of information needs for low-socioeconomic status women with high-risk pregnancies, specifically within the management of their mental health. This qualitative study consists of semi-structured focus groups and interviews with a sample of nineteen patients. A total of eleven core themes emerged from participant comments. Resulting themes highlighted the need for digital technologies that promote personalized care, a sense of community, and improved provider communication.

Background/Aims Obtaining ethical approval from multiple institutional review boards is a long-standing challenge to multi-site clinical trials and often leads to significant delays in study activation and enrollment. As of 25 January 2018, the National Institutes of Health began requiring use of a single institutional review board for US multi-site trials. To learn more and further inform the research and regulatory communities around aspects of transitioning to single institutional review board review, this study evaluated the efficiency, resource use, and user perceptions of a nascent institutional review board reliance model (Streamlined, Multi-site, Accelerated Resources for Trials IRB Reliance). Methods This research was embedded within the Influenza Vaccine to Effectively Stop Cardio Thoracic Events and Decompensated Heart Failure trial—a multi-site trial of two influenza vaccine formulations. In the first year of the trial, a sample of sites agreed to use the developing Streamlined, Multi-site, Accelerated Resources for Trials IRB Reliance model and participated in its evaluation. In keeping with a least burdensome approach, short surveys were developed and obtained from each reporting entity (relying sites, non-relying site, lead site, and reviewing institutional review board). Data regarding time to institutional review board approval and site activation, costs, and user perceptions of reliant review were self-reported and collected via the survey form. Quantitative and qualitative analyses were performed, with costs analyzed as actual versus estimated due to the lack of established baseline cost data. Results A total of 13 sites ceded review and received institutional review board approval. Mean time to approval was substantially faster in sites that ceded review using the Streamlined, Multi-site, Accelerated Resources for Trials IRB Reliance model versus the site that did not cede review (81 vs 121 days). The mean time to approval was also faster than published averages for academic medical centers (81 vs 103 days). Time to first enrollment was faster for ceding sites versus the non-ceding site, and also faster than published averages (126 vs 149 and 169 days, respectively). Costs were higher than estimates for local institutional review board review and approval. Nearly half (47%) the stakeholders reported being very satisfied or satisfied with the reliance experience, although many noted the challenge related to institutional culture change. Conclusion Implementation of a single institutional review board represents a shift in practice and culture for many institutions. Evaluation of the reliance arrangements for this study highlights both the potential of, and challenges for, institutions as they transition to single institutional review board review. Although efficiencies were observed for study start-up, we anticipate a learning curve as institutions and research teams implement necessary process and resource changes to adapt to single institutional review board oversight. Findings may inform research teams but are, however, limited by the relatively small number of sites and lack of a control group.

BACKGROUND Peripartum depression has an incidence rate of approximately 11% among pregnant women and new mothers in the U.S, yet many cases go undiagnosed and untreated due to psychosocial and logistical barriers. The interdisciplinary nature of PPD management presents a challenging scenario for communication and coordination between care providers and patients. Digital technologies offer many opportunities to improve mental healthcare management for women seeking pre- and-postnatal care. They provide a discrete, practical medium that is well-suited for the sensitive nature of mental health. However, current digital interventions in this domain provide suboptimal support and their responsiveness to end user needs is quite limited. OBJECTIVE Our objective is to map the terrain of information needs of women seeking pre-and-postnatal care, specifically for the management of their mental health. Ultimately, we will apply the derived insights to inform our development efforts of a novel digital solution to be used in an academic clinical setting. METHODS This qualitative study consists of semi-structured focus group interviews with a total of nine patients receiving care at an academic Obstetrics and Gynecology clinic. Discussion questions covered topics such as smartphone use and pregnancy apps. A total of two sessions were conducted and audio recorded. Data from the recordings were analyzed through thematic analysis. Overarching themes and views from the sessions were annotated. A survey was also administered to assess participants’ information seeking behavior and use of popular applications. RESULTS Access to smartphones and data plans was not an issue for participants. All used at least one pregnancy app, and three used additional health apps such as pedometers. Easy access to informational and human resources such as evidenced-based pregnancy information, their healthcare providers, and their peers was common across participants. The sense of community offered in discussion boards was also important to participants. Lack of postpartum support and limited personalization of user experience in current digital tools were identified as gaps and barriers for management of PPD and other mental health disorders. Digital technology features recommended by participants were: 1) a journaling feature, 2) online library of keywords linking to credible information, 3) a responsive bi-directional communication pathway to interact with their clinical team, and 4) personalized support for second pregnancy, diabetes, and prior depressive episodes. CONCLUSIONS Users prefer digital technology systems that go beyond a generic approach. They also want these systems to be adaptable to their needs at the moment, whether it is consulting with their provider or simply seeking peer support. Future technologies aimed at maternal mental health should focus on the individual needs of patients, while at the same time offering them common digital tools such as online communities and easy access to reliable information. CLINICALTRIAL N/A

BACKGROUND Although there is a rise in the use of mobile health (mHealth) tools to support chronic disease management, evidence derived from theory-driven design is lacking. OBJECTIVE The objective of this study was to determine the impact of an mHealth app that incorporated theory-driven trigger messages. These messages took different forms following the Fogg behavior model (FBM) and targeted self-efficacy, knowledge, and self-care. We assess the feasibility of our app in modifying these behaviors in a pilot study involving individuals with diabetes. METHODS The pilot randomized unblinded study comprised two cohorts recruited as employees from within a health care system. In total, 20 patients with type 2 diabetes were recruited for the study and a within-subjects design was utilized. Each participant interacted with an app called capABILITY. capABILITY and its affiliated trigger (text) messages integrate components from social cognitive theory (SCT), FBM, and persuasive technology into the interactive health communications framework. In this within-subjects design, participants interacted with the capABILITY app and received (or did not receive) text messages in alternative blocks. The capABILITY app alone was the control condition along with trigger messages including spark and facilitator messages. A repeated-measures analysis of variance (ANOVA) was used to compare adherence with behavioral measures and engagement with the mobile app across conditions. A paired sample t test was utilized on each health outcome to determine changes related to capABILITY intervention, as well as participants’ classified usage of capABILITY. RESULTS Pre- and postintervention results indicated statistical significance on 3 of the 7 health survey measures (general diet: P=.03; exercise: P=.005; and blood glucose: P=.02). When only analyzing the high and midusers (n=14) of capABILITY, we found a statistically significant difference in both self-efficacy (P=.008) and exercise (P=.01). Although the ANOVA did not reveal any statistically significant differences across groups, there is a trend among spark conditions to respond more quickly (ie, shorter log-in lag) following the receipt of the message. CONCLUSIONS Our theory-driven mHealth app appears to be a feasible means of improving self-efficacy and health-related behaviors. Although our sample size is too small to draw conclusions about the differential impact of specific forms of trigger messages, our findings suggest that spark triggers may have the ability to cue engagement in mobile tools. This was demonstrated with the increased use of capABILITY at the beginning and conclusion of the study depending on spark timing. Our results suggest that theory-driven personalization of mobile tools is a viable form of intervention. CLINICALTRIAL ClinicalTrials.gov NCT04132089; http://clinicaltrials.gov/ct2/show/NCT004122089

Building high-quality annotated clinical corpora is necessary for developing statistical Natural Language Processing (NLP) models to unlock information embedded in clinical text, but it is also time consuming and expensive. Consequently, it important to identify factors that may affect annotation time, such as syntactic complexity of the text- to-be-annotated and the vagaries of individual user behavior. However, limited work has been done to understand annotation of clinical text. In this study, we aimed to investigate how factors inherent to the text affect annotation time for a named entity recognition (NER) task. We recruited 9 users to annotate a clinical corpus and recorded annotation time for each sample. Then we defined a set of factors that we hypothesized might affect annotation time, and fitted them into a linear regression model to predict annotation time. The linear regression model achieved an R(2) of 0.611, and revealed eight time-associated factors, including characteristics of sentences, individual users, and annotation order with implications for the practice of annotation, and the development of cost models for active learning research.

Background Although there is a rise in the use of mobile health (mHealth) tools to support chronic disease management, evidence derived from theory-driven design is lacking. Objective The objective of this study was to determine the impact of an mHealth app that incorporated theory-driven trigger messages. These messages took different forms following the Fogg behavior model (FBM) and targeted self-efficacy, knowledge, and self-care. We assess the feasibility of our app in modifying these behaviors in a pilot study involving individuals with diabetes. Methods The pilot randomized unblinded study comprised two cohorts recruited as employees from within a health care system. In total, 20 patients with type 2 diabetes were recruited for the study and a within-subjects design was utilized. Each participant interacted with an app called capABILITY. capABILITY and its affiliated trigger (text) messages integrate components from social cognitive theory (SCT), FBM, and persuasive technology into the interactive health communications framework. In this within-subjects design, participants interacted with the capABILITY app and received (or did not receive) text messages in alternative blocks. The capABILITY app alone was the control condition along with trigger messages including spark and facilitator messages. A repeated-measures analysis of variance (ANOVA) was used to compare adherence with behavioral measures and engagement with the mobile app across conditions. A paired sample t test was utilized on each health outcome to determine changes related to capABILITY intervention, as well as participants’ classified usage of capABILITY. Results Pre- and postintervention results indicated statistical significance on 3 of the 7 health survey measures (general diet: P=.03; exercise: P=.005; and blood glucose: P=.02). When only analyzing the high and midusers (n=14) of capABILITY, we found a statistically significant difference in both self-efficacy (P=.008) and exercise (P=.01). Although the ANOVA did not reveal any statistically significant differences across groups, there is a trend among spark conditions to respond more quickly (ie, shorter log-in lag) following the receipt of the message. Conclusions Our theory-driven mHealth app appears to be a feasible means of improving self-efficacy and health-related behaviors. Although our sample size is too small to draw conclusions about the differential impact of specific forms of trigger messages, our findings suggest that spark triggers may have the ability to cue engagement in mobile tools. This was demonstrated with the increased use of capABILITY at the beginning and conclusion of the study depending on spark timing. Our results suggest that theory-driven personalization of mobile tools is a viable form of intervention. Trial Registration ClinicalTrials.gov NCT04132089; http://clinicaltrials.gov/ct2/show/NCT004122089

With the growth of gerontechnology, there is an increasing awareness of the importance of accessibility and usability in product designs7. Here we consider the degree to which those factors along with patient engagement are currently being provided by mobile health applications aimed towards an older population. Specifically, we used a hybrid usability checklist, that is inclusive of age related guidelines and mobile platform atributes along with HIMSS Patient Engagement Framework to evaluate accessibility, usability, and engagement levels facilitated by the mobile apps targeting older adults. Expert review found a limited range of features to support accessibility and significant violations of general usability heuristics. Analyses of Patient Engagement levels suggest that the majority of the apps provide information and way finding, education, and community support. However, utilization of health monitoring tools, record-keeping features, and shared decision making with providers has been minimal. Implications for care coordination and technology design for enabling independent living are discussed.

Connected health solutions provide novel pathways to provide integrated and affordable care. Emerging research suggests these connected tools can result improved health outcomes and sustainable self-health management. However, current health technology frameworks limit flexibility, engagement, and reusability of underlying connected health components. The objective of this paper is to develop a data-driven consumer engagement framework, which we call Digilego, to facilitate development of connected health solutions that are targeted, modular, extensible, and engaging. The major components include social media analysis, patient engagement features, and behavioral intervention technologies. We propose implementation of these Digilego components using FHIR specification such that the resulting technology is compliant to industry standards. We apply and evaluate the proposed framework to characterize four individual building blocks (DigiMe, DigiSocial, DigiConnect, DigiEHR) for a connected health solution that is responsive to cancer survivor needs. Results indicate that the framework (a) allows identification of survivor needs (e.g. social integration, treatment side effects) through semi-automated social media analysis, (b) facilitates infusion of engagement elements (e.g. smart health trackers, integrated electronic health records), and (c) integrates behavior change constructs into the design architecture of survivorship applications (e.g. goal setting, emotional coping). End user evaluation with 16 cancer survivors indicated general user acceptance and enthusiasm to adopt the solution for self-care management. Implications for design of patient-engaging chronic disease management solutions are discussed.

Objective Critical care environments are informationintensive environments where effective decisions are predicated on successfully finding and using the ‘right information at the right time’. We characterize the differences in processes and strategies of information seeking between residents, nurse practitioners (NPs), and physician assistants (PAs). Method We conducted an exploratory study in the cardiothoracic intensive care units of two large academic hospitals within the same healthcare system. Clinicians (residents (n=5), NPs (n=5), and PAs (n=5)) were shadowed as they gathered information on patients in preparation for clinical rounds. Information seeking activities on 96 patients were collected over a period of 3 months (NRes=37, NNP=24, NPA=35 patients). The sources of information and time spent gathering the information at each source were recorded. Exploratory data analysis using probabilistic sequential approaches was used to analyze the data. Results Residents predominantly used a patient-based information seeking strategy in which all relevant information was aggregated for one patient at a time. In contrast, NPs and PAs primarily utilized a source-based information seeking strategy in which similar (or equivalent) information was aggregated for multiple patients at a time (eg, X-rays for all patients). Conclusions The differences in the information seeking strategies are potentially a result of the differences in clinical training, strategies of managing cognitive load, and the nature of the use of available health IT tools. Further research is needed to investigate the effects of these differences on clinical and process outcomes.

Providing timely and effective care in the emergency department (ED) requires the management of individual patients as well as the flow and demands of the entire department. Strategic changes to work processes, such as adding a flow coordination nurse or a physician in triage, have demonstrated improvements in throughput times. However, such global strategic changes do not address the real-time, often opportunistic workflow decisions of individual clinicians in the ED. We believe that real-time representation of the status of the entire emergency department and each patient within it through information visualizations will better support clinical decision-making in-the-moment and provide for rapid intervention to improve ED flow. This notion is based on previous work where we found that clinicians' workflow decisions were often based on an in-the-moment local perspective, rather than a global perspective. Here, we discuss the challenges of designing and implementing visualizations for ED through a discussion of the development of our prototype Throughput Dashboard and the potential it holds for supporting real-time decision-making.

In many respects, the critical care workplace resembles a paradigmatic complex system: on account of the dynamic and interactive nature of collaborative clinical work, these settings are characterized by non-linear, inter-dependent and emergent activities. Developing a comprehensive understanding of the work activities in critical care settings enables the development of streamlined work practices, better clinician workflow and most importantly, helps in the avoidance of and recovery from potential errors. Sensor-based technology provides a flexible and viable way to complement human observations by providing a mechanism to capture the nuances of certain activities with greater precision and timing. In this paper, we use sensor-based technology to capture the movement and interactions of clinicians in the Trauma Center of an Emergency Department (ED). Remarkable consistency was found between sensor data and human observations in terms of clinician locations and interactions. With this validation and greater precision with sensors, ED environment was characterized in terms of (a) the degree of randomness or entropy in the environment, (b) the movement patterns of clinicians, (c) interactions with other clinicians and finally, (d) patterns of collaborative organization with team aggregation and dispersion. Based on our results, we propose three opportunities for the use of sensor technologies in critical care settings: as a mechanism for real-time monitoring and analysis for ED activities, education and training of clinicians, and perhaps most importantly, investigating the root-causes, origins and progression of errors in the ED. Lessons learned and the challenges encountered in designing and implementing the sensor technology sensor data are discussed.

In critical care environments such as the emergency department (ED), many activities and decisions are not planned. In this study, we developed a new methodology for systematically studying what are these unplanned activities and decisions. This methodology expands the traditional naturalistic decision making (NDM) frameworks by explicitly identifying the role of environmental factors in decision making. We focused on decisions made by ED physicians as they transitioned between tasks. Through ethnographic data collection, we developed a taxonomy of decision types. The empirical data provide important insight to the complexity of the ED environment by highlighting adaptive behavior in this intricate milieu. Our results show that half of decisions in the ED we studied are not planned, rather decisions are opportunistic decision (34%) or influenced by interruptions or distractions (21%). What impacts these unplanned decisions have on the quality, safety, and efficiency in the ED environment are important research topics for future investigation.

When children learn language, they apply their language-learning skills to the linguistic input they receive. But what happens if children are not exposed to input from a conventional language? Do they engage their language-learning skills nonetheless, applying them to whatever unconventional input they have? We address this question by examining gesture systems created by four American and four Chinese deaf children. The children’s profound hearing losses prevented them from learning spoken language, and their hearing parents had not exposed them to sign language. Nevertheless, the children in both cultures invented gesture systems that were structured at the morphological/word level. Interestingly, the diVerences between the children’s systems were no bigger across cultures than within cultures. The children’s morphemes could not be traced to their hearing mothers’ gestures; however, they were built out of forms and meanings shared with their mothers. The Wndings suggest that children construct morphological structure out of the input that is handed to them, even if that input is not linguistic in form. © 2007 Published by Elsevier Inc.

Studies show that current modes of psychoeducation (PE) cannot be availed of by a substantial population of those in need. Mobile health technologies have great potential to serve such populations. However converting PE to mobile platforms is challenging. We present a methodology for this purpose based on existing learning styles theory, and developed PE apps successfully, using it.Useful PE apps can be developed easily using the proposed method.

Interruptions are an often lamented and frequently studied aspect of clinical practice. However, some interruptions, such as updates on patient care decisions and notifications of detrimental patient lab values, are in fact necessary to the work process. In this paper, we explore the interruptions as an emergent feature of communication in teams. Looking beyond the frequency of interruptions, we consider the source and intent of interruptions with the goal of discovering the functions served by such communications. Furthermore, in this study of an emergency department, we classify interruptions into those activities that support required work and those interruptions that create unnecessary breaks in workflow. The intent of our larger body of work is to develop health information technology systems that support team efforts including the functions currently served by interruptions.

In this chapter, we highlight unexpected outcomes created by technology use in clinical settings. We define unintended consequences as both positive serendipitous results as well as negative, unintended, and potentially harmful consequences of technology in use. A review of different classification systems for studying the unanticipated impacts of health information technology (HIT) is followed by specific examples from the use of electronic health records (EHR). EHR systems are one example of how even well-designed technology can yield unexpected results. Although HIT such as EHRs has the potential to improve care by reducing the burden placed on its users, it can also increase memory demands, alter communication channels, and provoke sub-optimal decision-making. This can lead to errors, inefficiencies in workflows, overdependence on technology and, importantly, risk to patients. By understanding the impact of technology on performance we can potentially manage the negative unintended consequences engendered by HIT systems allowing such systems to function as expected. Additionally, by understanding unanticipated beneficial outcomes, we can promote the development of future tools that further induce positive results.

Objective Medical record abstraction (MRA) is often cited as a significant source of error in research data, yet MRA methodology has rarely been the subject of investigation. Lack of a common framework has hindered application of the extant literature in practice, and, until now, there were no evidence-based guidelines for ensuring data quality in MRA. We aimed to identify the factors affecting the accuracy of data abstracted from medical records and to generate a framework for data quality assurance and control in MRA. Methods Candidate factors were identified from published reports of MRA. Content validity of the top candidate factors was assessed via a four-round two-group Delphi process with expert abstractors with experience in clinical research, registries, and quality improvement. The resulting coded factors were categorized into a control theory-based framework of MRA. Coverage of the framework was evaluated using the recent published literature. Results Analysis of the identified articles yielded 292 unique factors that affect the accuracy of abstracted data. Delphi processes overall refuted three of the top factors identified from the literature based on importance and five based on reliability (six total factors refuted). Four new factors were identified by the Delphi. The generated framework demonstrated comprehensive coverage. Significant underreporting of MRA methodology in recent studies was discovered. Conclusion The framework generated from this research provides a guide for planning data quality assurance and control for studies using MRA. The large number and variability of factors indicate that while prospective quality assurance likely increases the accuracy of abstracted data, monitoring the accuracy during the abstraction process is also required. Recent studies reporting research results based on MRA rarely reported data quality assurance or control measures, and even less frequently reported data quality metrics with research results. Given the demonstrated variability, these methods and measures should be reported with research results.

This chapter discusses the cognitive and usability factors for complex team environments by exploring the challenges brought about by human cognitive limitations and the unintended consequences of technology. In the final sections, both the challenges and opportunities in a distributed cognition framework are presented.

Healthcare as a complex system [1] is exemplified in emergency medicine [2, 3]. Emergency Departments (EDs) are dynamic, adaptive, and self-organizing. Additionally, ED providers are faced with inherent unpredictability regarding the number and severity of patients, concurrent management of multiple individuals requiring timely responses, and a need to cope with limited resources all within a life-critical, interruption-laden environment [4]. The layered complexity of such units includes the functions of the work, the implementation of technology, the people, the activities and workflows jointly performed by the people and the technology, as well as the social, physical, cultural, and organizational environment in which the ED is embedded. Managing the cognitive, physical, spatial, and temporal resources in such systems is crucial for patient safety and quality of care. Understanding the interaction of the complexity of this work and the environment, particularly as it relates to decision-making, is a first step in engineering solutions to support physician efforts.

Clinical rounds are a critical time for determining a patient’s daily and long-term goals, for communicating these goals to a patients’ healthcare team and to family, and for teaching medical students and other clinicians. However, these discussions are highly variable ranging from highly structured monologues at some sites to free form dialogues in other units [1–7]. Best practices and standards for round discussions are still emerging. As discussed in Lane et al.’s [8] review of the literature, known barriers to round quality include interruptions, long rounding times, and poor information retrieval. Given rounds’ importance for team communication [9–11] and patient care, significant effort is being put forth to improve round quality. For example, tools such as scripts and checklists are proven to hasten the rounds process and increase the rounding teams’ satisfaction [1, 3, 5, 7, 12–14].

Human information seeking is driven by their need to satisfy their various needs [1] related to specific tasks and activities. The effectiveness of information seeking is critical in achieving high throughput and efficiency. Nevertheless, given the plethora of available data it is impossible to effectively focus on specific data – cognitive barriers such as information load, memory capacity and strategies significantly affect the effectiveness of information seeking and gathering. While much is known about the information needs and sources of information that are typically used by clinicians (both physicians, nurses and other healthcare professionals) very little is known about the processes and mechanisms that underlie the clinicians’ use of the information sources. Additionally, most of the prior work on information needs and use has been conducted in primary care settings.

Neural tube defects (NTD) are one of the most common birth defects and are caused by both environmental and genetic factors. The approach to identifying the genes predisposing to NTD, through linkage analysis and candidate gene analysis, is reviewed along with characteristics of a large, nationally ascertained cohort of families. Results from specific assessments of p53, PAX3 and MTHFR failed to suggest that these genes play a major role in NTD development in these families. Advances in genetic laboratory and statistical techniques have made this a prime opportunity for investigation into the causes of complex disorders, such as NTD. However, traditional approaches may prove to be challenging due to the difficulty of ascertaining samplable multiplex families.

Objective: Information in critical care environments is distributed across multiple sources, such as paper charts, electronic records, and support personnel. For decision-making tasks, physicians have to seek, gather, filter and organize information from various sources in a timely manner. The objective of this research is to characterize the nature of physicians' information seeking process, and the content and structure of clinical information retrieved during this process. Method: Eight medical intensive care unit physicians provided a verbal think-aloud as they performed a clinical diagnosis task. Verbal descriptions of physicians' activities, sources of information they used, time spent on each information source, and interactions with other clinicians were captured for analysis. The data were analyzed using qualitative and quantitative approaches. Results: We found that the information seeking process was exploratory and iterative and driven by the contextual organization of information. While there was no significant differences between the overall time spent paper or electronic records, there was marginally greater relative information gain (i.e., more unique information retrieved per unit time) from electronic records (t(6)=1.89, p=0.1). Additionally, information retrieved from electronic records was at a higher level (i.e., observations and findings) in the knowledge structure than paper records, reflecting differences in the nature of knowledge utilization across resources. Conclusion: A process of local optimization drove the information seeking process: physicians utilized information that maximized their information gain even though it required significantly more cognitive effort. Implications for the design of health information technology solutions that seamlessly integrate information seeking activities within the workflow, such as enriching the clinical information space and supporting efficient clinical reasoning and decision-making, are discussed.

Online courses will play a key role in the high-volume Informatics education required to train the personnel that will be necessary to fulfill the health IT needs of the country. Online courses can cause feelings of isolation in students. A common way to address these feelings is to hold synchronous online “chats” for students. Conventional chats, however, can be confusing and impose a high extrinsic cognitive load on their participants that hinders the learning process. In this paper we present a qualitative analysis that shows the causes of this high cognitive load and our solution through the use of a moderated chat system.

Preschool children (n=30) undergoing routine immunizations at a health department were taught to use distraction prior to the medical procedure and to use a party blower, as an age appropriate version of deep breathing, just prior to and during the injection. Parents were taught to coach their children. A no-treatment control group (n=30) was used to evaluate effectiveness. Results indicated that trained parents engaged in more prompting of their child to use the blower than untrained parents. Trained children engaged in more blower usage than untrained children. Child distress was lower on two of three observational measures for the trained children. Parents of trained children reported that both they and their children were less distressed when compared to how they normally would be during the procedures. Staff, who were not trained nor instructed to change their behavior, engaged in significantly more coaching of trained than of untrained children to use the blower, suggesting generalization of the behavior from parents to staff. Suggestions for future research are included.

Neural tube defects are a common, complex disorder with genetic and environmental components to risk. We investigated the previously reported interaction between homozygosity for the thermolabile variant at the methylenetetrahydrofolate reductase and heterozygosity for the 844ins68 allele at the cystathionine beta-synthase loci in cases with lumbosacral myelomeningocele and their parents. Using control allele frequencies from our sample pooled with those published in the literature, we confirm a marginally significant interaction at these two loci. This finding suggests that additional, larger studies are warranted to investigate this possible interaction in more detail.

In several reports the authors have suggested occasional familial aggregation of syringomyelia and/or Chiari 1 malformation (CM1). Familial aggregation is one characteristic of traits that have an underlying genetic basis. The authors provide evidence for familial aggregation of CM1 and syringomyelia (CM1/S) in a large series of families, establishing that there may be a genetic component to CM1/S in at least a subset of families. The authors observed no cases of isolated familial syringomyelia in their family studies, suggesting that familial syringomyelia is more accurately classified as familial CM1 with associated syringomyelia. These data, together with the cosegregation of the trait with known genetic syndromes, support the authors' hypothesis of a genetic basis for some CM1/S cases.

The participant in a human-to-human communication who controls the floor bears the burden of moving the communication process along. Change in control of the floor can happen through a number of mechanisms, including interruptions, delegation of the floor, and so on. This paper investigates floor control in multiparty meetings that are both audio and video taped; hence, we are able to analyze patterns not only of speech (e.g., discourse markers) but also of visual cues (e.g, eye gaze exchanges) that are commonly involved in floor control changes. Identifying who has control of the floor provides an important focus for information retrieval and summarization of meetings. Additionally, without understanding who has control of the floor, it is impossible to identify important events such as challenges for the floor. In this paper, we analyze multimodal cues related to floor control in two different meetings involving five participants each.