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[ES] Objetivo: Evaluar las fuentes de información empleadas por los Registros Autonómicos de Enfermedades Raras (RAER) para la captación de la enfermedad de Wilson en España, calcular su prevalencia y mortalidad, y describir las características sociodemográficas de las personas afectadas. Método: Estudio epidemiológico transversal, periodo 2010-2015. Se captaron los posibles casos mediante los códigos 275.1 (CIE-9-MC), E83.0 (CIE-10) y 905 ORPHA en 15 RAER y el Registro de Pacientes de Enfermedades Raras del Instituto de Salud Carlos III. Los diagnósticos fueron validados revisando la documentación clínica. Se calcularon el valor predictivo positivo (VPP) de las fuentes de información, la prevalencia, la mortalidad y la distribución de las características sociodemográficas. Resultados: El Conjunto Mínimo Básico de Datos (CMBD) fue la fuente de información más utilizada por los RAER (VPP = 39,4%), seguida del Registro de Medicamentos Huérfanos (RMH) (VPP = 81,9%). La Historia Clínica de Atención Primaria (HCAP) obtuvo un VPP del 55,9%. Las combinaciones con mayor VPP fueron las del RMH con el CMBD (VPP = 95,8%) y del RMH con la HCAP (VPP = 92,9%). Se confirmaron 514 casos, el 57,2% eran hombres, cuya edad mediana de diagnóstico fue de 21,3 años. La prevalencia fue de 1,64/100.000 habitantes en 2015 y la mortalidad del 3,0%, siendo ambas superiores en los hombres. Conclusión: Se recomienda la incorporación en los RAER del RMH y de la HCAP, ya que su combinación y la del RMH con el CMBD podrían utilizarse como criterio de validación automática para la enfermedad de Wilson. La prevalencia obtenida fue similar a la de otros países próximos a España. [EN] Objective: To evaluate the sources of information used by the Regional Population-based Registries of Rare Diseases (RRD) for Wilson's Disease identification in Spain; to calculate its prevalence and mortality; and to describe the sociodemographic characteristics of those affected. Method: Cross-sectional epidemiological study, period 2010-2015. Possible cases were identified by codes 275.1 (ICD-9-CM), E83.0 (ICD-10) and 905 (ORPHAcode) in: 15 participating RRD and the Rare Disease Patients Registry of the Carlos III Health Institute. The diagnoses were confirmed through a clinical documentation review. The positive predictive value (PPV) of the sources of information used by RRD and their combinations were obtained. The prevalence, mortality and the distribution of sociodemographic characteristics were calculated. Results: The Hospital Discharge Database (HDD) was the most used source by the RRD (PPV=39.4%), followed by the Orphan Drugs Registry (ODR) (PPV=81.9%). The Clinical History of Primary Care (PC) obtains PPV=55.9%. The combinations with highest PPV were the ODR with HDD (PPV=95.8%) and the ODR with PC (PPV=92.9%). 514 cases were confirmed, 57.2% men, with a median age of diagnosis of 21.3 years. The prevalence was 1.64/100,000 inhabitants in 2015 and mortality rate was 3.0%, being both higher in men. Conclusions: Incorporation of ODR and PC into the RRD is recommended, as its combination and ODR with HDD could be used as an automatic validation criterion for Wilson's disease. The prevalence obtained was similar to that of countries close to Spain. Este proyecto ha sido posible gracias a los fondos recibidos por la Fundació Per Amor a l’Art (Convenio CPRESC00043). Sí

Resumo Trata-se de um estudo ecológico que objetivou analisar a tendência do estado nutricional de gestantes adolescentes beneficiárias do programa brasileiro de transferência condicionada de renda, Bolsa Família, no período 2008-2018. Foram avaliados dados secundários de gestantes adolescentes beneficiárias do Programa Bolsa Família no período de janeiro de 2008 a dezembro de 2018, extraídos dos relatórios públicos do Sistema de Vigilância Alimentar e Nutricional WEB. Foram consultados os relatórios de acompanhamento das condicionalidades de saúde consolidados de acesso público do Programa Bolsa Família, sempre considerando a 2ª vigência. Observou-se uma variação anual de -1,2% (IC95%: [-1,6; -0,8] p

Background The electronic health record (EHR) has become increasingly ubiquitous. At the same time, health professionals have been turning to this resource for access to data that is needed for the delivery of health care and for clinical research. There is little doubt that the EHR has made both of these functions easier than earlier days when we relied on paper-based clinical records. Coupled with modern database and data warehouse systems, high-speed networks, and the ability to share clinical data with others are large number of challenges that arguably limit the optimal use of the EHR Objectives Our goal was to provide an exhaustive reference for those who use the EHR in clinical and research contexts, but also for health information systems professionals as they design, implement, and maintain EHR systems. Methods This study includes a panel of 24 biomedical informatics researchers, information technology professionals, and clinicians, all of whom have extensive experience in design, implementation, and maintenance of EHR systems, or in using the EHR as clinicians or researchers. All members of the panel are affiliated with Penn Medicine at the University of Pennsylvania and have experience with a variety of different EHR platforms and systems and how they have evolved over time. Results Each of the authors has shared their knowledge and experience in using the EHR in a suite of 20 short essays, each representing a specific challenge and classified according to a functional hierarchy of interlocking facets such as usability and usefulness, data quality, standards, governance, data integration, clinical care, and clinical research. Conclusion We provide here a set of perspectives on the challenges posed by the EHR to clinical and research users.

Objectives This study explored health workers' perceptions and experiences regarding the maternal and neonatal referral system, focusing on barriers of health information systems and technologies (IS/IT) at primary health centers (PHCs) in South Tangerang, Indonesia. Methods This qualitative study was conducted using semi-structured interviews, which were conducted at the South Tangerang District Health Office and three PHCs. Interviews were conducted with nine participants responsible for maternal and neonatal referrals in their organizations. The data were analyzed using qualitative content analysis. Results In South Tangerang, the Primary Health Care Information System (SIMPUS) is used to register patients and record data on medical treatment. To facilitate referrals, the PHCs currently use the Integrated Referral Information System (SISRUTE), P-Care, and the Integrated Emergency Management System (SPGDT). The following four IS/IT barriers to support maternal and neonatal referrals were found: technology, human resources, organizational support, and the referral process and implementation. Conclusions The barriers in technology, human resources, and organizational support cause problems in the maternal and neonatal referral process and in the implementation of referrals. Barriers to referrals can influence patients' ability to receive appropriate care in a timely fashion and lead to inefficiency in maternal and neonatal referrals. This study contributes knowledge about IS/IT implementation in maternal and neonatal referral systems and provides recommendations to health regulators and application developers for the implementation of IS/IT in Indonesia.

Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) is a validated tool for capturing a patient's perception of their physical capacity. The goal of this study was to determine whether preoperative PF correlates with a risk of postoperative complications.Patients from a single-institution American College of Surgeons NSQIP database undergoing elective colorectal abdominal operations from January 2018 to June 2019 with a preoperative PROMIS-PF T-score were eligible for this retrospective study. Patients were divided into moderate to severe (score40) and minimal to mild (score ≥40) physical disability cohorts. Primary outcomes were any complication and any Clavien-Dindo grade III or higher complication. Multivariate logistic regression was performed.In total, 249 patients were included: 78 (31%) with self-scored moderate to severe disability and 171 (69%) with minimal to mild disability. Patients who scored as moderate to severe disability had a higher frequency of comorbidities and an open operative approach compared with patients with minimal to mild disability. These patients then had higher rates of any complication (37.2% vs 19.9%; p = 0.0036) and Clavien-Dindo grade III or higher complications (14.1% vs 7.6%; p = 0.017). After adjusting for patient factors, surgical procedure, and approach, patients scoring as moderate to severe disability were 2.00 times more likely (95% CI, 1.05 to 3.84; p = 0.036) to have any complication and 2.76 times more likely (95% CI, 1.07 to 7.14; p = 0.036) to have a Clavien-Dindo grade III or higher complication.Moderate to severe PF disability score is associated with increased risk of postoperative complications among patients undergoing colorectal operations. PROMIS-PF T-score can be a useful tool to identify patients who would benefit from targeted preoperative interventions, such as patient education, nutritional optimization, and prehabilitation.

In West and Central Africa, “leaving no one behind” requires strengthening community health systems by increasing health financing, improving supply chain system, and fostering community ownership and partnerships in all settings. Countries with high child mortality rates should improve service delivery through better integration. Galvanizing context-specific country actions is fundamental to improve primary health care services and move toward universal health coverage., Key Findings Challenges with health financing, essential medical products and technology, and community ownership and partnerships emerged as the severe or very severe health system bottlenecks that hampered the strengthening of community health systems, irrespective of mortality context. Country-led progress is possible. Potential strategies to overcome bottlenecks include increasing domestic allocation and leveraging innovative funding mechanisms for primary health care (PHC), integrating supply chain systems, and strengthening policy implementation with communities and local governments. Countries with high child mortality rates should improve service delivery through better integration. Key Implications Countries must seize the opportunities to systematically strengthen community health systems in their efforts to achieve universal health coverage. We must galvanize efforts to mobilize resources for effective PHC, which is reliant on strong community health systems to expand access to services and live no one behind. Community-based integrated programming should be reinforced to strengthen resilience, disease surveillance, and rapid responses to health crises, including infectious diseases like COVID-19., Introduction: The renewed commitment to primary health care (PHC) presents an opportunity to strengthen health systems in West and Central Africa (WCA). Though evidence-based cost-effective interventions that are predicted to prevent up to one-third of maternal, newborn, and child health complications and deaths with universal coverage have been identified, more than 50% of people living in rural areas or from poor families still do not have access to these interventions in resource-constrained settings. Methods: We conducted a multicountry systematic analysis of bottlenecks and proposed solutions to strengthen community health systems through a series of collaborative workshops in 22 countries in WCA. Countries were categorized by their under-5 mortality rate (U5MR) to assess specificities related to reported challenges. We also reviewed existing data on selected health system tracer interventions to analyze country profiles. Results: The bottlenecks identified as severe or very severe were related to health financing (19 countries, 86%), essential medical technology and products (16 countries, 73%), integrated health service delivery (14 countries, 64%), and community ownership and partnerships (self-reported by 14 countries, 64%). Only the integrated service delivery was self-reported as a severe challenge by countries with high U5MR. The issue of human resources for community health was one of the least reported challenges. Conclusion: In WCA, strengthening community health systems as part of PHC revitalization efforts should focus on increasing health financing and innovative investments, strengthening the logistics management system, and fostering community ownership and partnerships. Countries with high U5MR should also reinforce integrated service delivery approaches through innovation. Government actions galvanized by global and regional ongoing initiatives should be sustained to ensure that no one is left behind.

This study investigates user perception and resistance against change in the Hospital Information System (HIS) change. A quantitative approach with a survey was applied to determine perception and resistance ofvgroups.The results were compared with each other: the percentage of innovators (32%), the percentage of early adopters (21%), the percentage of early majority (31%), and the percentage of late majority (12%), and the percentage of laggards (4%). Acceptance differs due to financial reasons. The resistance differs according to the employees’ status. IT developments, management supported security and privacy rules increase employee performance and acceptance. For resistance, there has been a significant difference feedback of employees is required, and functional needs reduce resistance. Hospitals need to use new and up-to-date information technology in order to serve effective patient care with valid standards., Bu çalışma, Hastane Bilgi Sistemi (HBS) değişikliğinde kullanıcının algılamasını ve değişime karşı direnci araştırmaktadır. Grupların algı ve direncini belirlemek için bir anket ile nicel bir yaklaşım uygulanmıştır. Sonuçlar birbirleriyle karşılaştırılmıştır: yenilikçilerin yüzdesi (% 32), erken benimseyenlerin yüzdesi (% 21), erken çoğunluğun yüzdesi (% 31) ) ve geç çoğunluk yüzdesi (% 12) ve gecikme yüzdesi (% 4). Kabul, finansal nedenlerden dolayı farklılık gösterir. Direnç çalışanların durumuna göre değişir. BT gelişmeleri, yönetim destekli güvenlik ve gizlilik kuralları çalışanların performansını ve kabulünü artırır. Direnç için, çalışanların geribildirimi önemli bir fark olmuştur ve fonksiyonel ihtiyaçlar direnci azaltır. Hastanelerin geçerli standartlarda etkili hasta bakımı sunmak için yeni ve güncel bilgi teknolojilerini kullanması gerekmektedir.

Implementing health information systems for enhancing patient care and management occurs worldwide. Discovering how nurses, as important system end-users, experience technology-reliant clinical practice involved focus groups (n = 25) and in-depth individual interviews with nurses (n = 4) and informatics staff (n = 3) in a major Taiwanese medical center. This qualitative study explores the unintended effects of these systems on nurses’ role and clinical practice. First, nurses’ additional role caring for computer devices supporting patient care involves highly-demanding invisible effort, especially when tackling system malfunctions affecting patients with urgent conditions. Second, nurses are resourceful in developing solutions to protect patients during unexpected technical malfunctions. Third, troubleshooting using telephone technical support as the first resort is problematic. It is argued that computerization requires nurses to care for co-clients: patients and computers. Managing technical malfunctions is an unintended consequence for nurses, reflecting the hidden work required by new technology.

Background Reliable surveillance systems are essential for identifying disease outbreaks and allocating resources to ensure universal access to diagnostics and treatment for endemic diseases. Yet, most countries with high disease burdens rely entirely on facility-based passive surveillance systems, which miss the vast majority of cases in rural settings with low access to health care. This is especially true for malaria, for which the World Health Organization estimates that routine surveillance detects only 14% of global cases. The goal of this study was to develop a novel method to obtain accurate estimates of disease spatio-temporal incidence at very local scales from routine passive surveillance, less biased by populations' financial and geographic access to care. Methods We use a geographically explicit dataset with residences of the 73,022 malaria cases confirmed at health centers in the Ifanadiana District in Madagascar from 2014 to 2017. Malaria incidence was adjusted to account for underreporting due to stock-outs of rapid diagnostic tests and variable access to healthcare. A benchmark multiplier was combined with a health care utilization index obtained from statistical models of non-malaria patients. Variations to the multiplier and several strategies for pooling neighboring communities together were explored to allow for fine-tuning of the final estimates. Separate analyses were carried out for individuals of all ages and for children under five. Cross-validation criteria were developed based on overall incidence, trends in financial and geographical access to health care, and consistency with geographic distribution in a district-representative cohort. The most plausible sets of estimates were then identified based on these criteria. Results Passive surveillance was estimated to have missed about 4 in every 5 malaria cases among all individuals and 2 out of every 3 cases among children under five. Adjusted malaria estimates were less biased by differences in populations’ financial and geographic access to care. Average adjusted monthly malaria incidence was nearly four times higher during the high transmission season than during the low transmission season. By gathering patient-level data and removing systematic biases in the dataset, the spatial resolution of passive malaria surveillance was improved over ten-fold. Geographic distribution in the adjusted dataset revealed high transmission clusters in low elevation areas in the northeast and southeast of the district that were stable across seasons and transmission years. Conclusions Understanding local disease dynamics from routine passive surveillance data can be a key step towards achieving universal access to diagnostics and treatment. Methods presented here could be scaled-up thanks to the increasing availability of e-health disease surveillance platforms for malaria and other diseases across the developing world.

Objective Robson's Ten Group Classification System (TGCS) creates clinically relevant sub‐groups for monitoring caesarean birth rates. This study assesses whether this classification can be derived from routine data in Europe and uses it to analyse national caesarean rates. Design Observational study using routine data. Setting Twenty‐seven EU member states plus Iceland, Norway, Switzerland and the UK. Population All births at ≥22 weeks of gestational age in 2015. Methods National statistical offices and medical birth registers derived numbers of caesarean births in TGCS groups. Main outcome measures Overall caesarean rate, prevalence and caesarean rates in each of the TGCS groups. Results Of 31 countries, 18 were able to provide data on the TGCS groups, with UK data available only from Northern Ireland. Caesarean birth rates ranged from 16.1 to 56.9%. Countries providing TGCS data had lower caesarean rates than countries without data (25.8% versus 32.9%, P = 0.04). Countries with higher caesarean rates tended to have higher rates in all TGCS groups. Substantial heterogeneity was observed, however, especially for groups 5 (previous caesarean section), 6, 7 (nulliparous/multiparous breech) and 10 (singleton cephalic preterm). The differences in percentages of abnormal lies, group 9, illustrate potential misclassification arising from unstandardised definitions. Conclusions Although further validation of data quality is needed, using TGCS in Europe provides valuable comparator and baseline data for benchmarking and surveillance. Higher caesarean rates in countries unable to construct the TGCS suggest that effective routine information systems may be an indicator of a country's investment in implementing evidence‐based caesarean policies. Tweetable abstract Many European countries can provide Robson's Ten‐Group Classification to improve caesarean rate comparisons., Tweetable abstract Many European countries can provide Robson's Ten‐Group Classification to improve caesarean rate comparisons.

Objectives To assess the safety of paediatric tonsillectomy procedures conducted in NHS hospitals in England between 2008 and 2019. Design Retrospective observational cohort study using Hospital Episode Statistics (HES) data. Setting Acute NHS trusts in England conducting paediatric tonsillectomy procedures. Participants Children (≤16 years old) undergoing bilateral tonsillectomy. Main outcome measures Number of tonsillectomies performed per year by procedural method. In‐hospital complications including return to theatre for arrest of haemorrhage. Readmission within 28 days, including those for pain, haemorrhage and surgical arrest of haemorrhage. Long‐term outcomes: all‐cause mortality, revision tonsillectomy. Results A total of 318 453 paediatric tonsillectomies were performed from 2008 to 2019:278,772 dissection (87.5%) and 39 681 coblation (12.5%). The proportion of tonsillectomy performed using coblation increased from 7% in 2008/9 to 27% in 2018/9. Five patients died in hospital (including 4 due to respiratory complications). In‐hospital complications occurred in 4202 children (1.3%), with the most frequent being haemorrhage. Within 28 days of tonsillectomy, 28 170 patients (8.8%) were readmitted and 7 deaths occurred. Readmission rates for haemorrhage and pain have increased since 2008. The proportion of children undergoing revision tonsillectomy procedures within 5 years following coblation tonsillectomy (1.4%) was approximately double that of dissection (0.6%). Conclusions Clinical practice of paediatric tonsillectomy has changed in England over the past 11 years. The overall mortality rate associated with the procedure is 0.0037%. Differences in outcomes have been identified for different procedural methods. However, routine administrative data are limited in differentiating procedural detail (eg we are unable to differentiate intra or extra‐capsular techniques from current clinical coding of tonsillectomy procedures). Therefore, prospective national data collection or more granular clinical coding is essential to capture relative outcomes of the different tonsillectomy methods and techniques being used in the NHS.

Background The Sars-CoV-2 pandemic exacerbates existing inequalities across health care systems globally, both within countries and between countries. It also highlights, like no other crisis before, existing weaknesses in health information systems (HIS). This article summarizes these key challenges for HIS in times of a pandemic and beyond, with a focus on European countries. It builds on the experiences of a large consortium representing HIS experts in key positions in national public health or similar institutes across Europe. Methods Data were collected in bi-weekly conference calls organized by the InfAct project between February and June 2020. Emerging themes were clustered and analysed around a WHO framework for health information systems (HIS). We analyse strengths of HIS at two levels: (i) dealing with health information directly, and (ii) dealing with other parts of information systems that allow for a holistic assessment of the pandemic (including health-related aspects). Results The analysis highlights the need for capacity-building in HIS before a pandemic hits, the relevance of going beyond health information only related to health care but taking a broader perspective (e.g. on vulnerable groups), the need for strong reporting systems on staffing numbers and in primary care. Further, data linkage emerges as a crucial precondition to identify unmet needs for essential health care services in a timely manner. Finally, room for innovation and digitalisation is key to be able to react flexibly in times of crisis. Trust for health information stakeholders is another important factor to create strong HIS. Conclusions The strengths and shortcomings of European HIS that have been observed during the COVID-19 crisis highlight the need for strong HIS beyond the crisis. The experiences reported leave as a central message that successful reactions to the pandemic are (also) grounded in strong HIS that ultimately not only benefit the health of the population but also create a number of economic and psycho-social benefits. Strong data reporting schemes may also support fine-tuning of containment measures during a pandemic as well as transition phases.

The analysis of large amounts of data from electronic medical records (EMRs) and daily clinical practice data sources has received increasing attention in the last years. However, few systematic approaches have been proposed to support the extraction of the wealth and diversity of information from these data sources. Specifically, Acute Coronary Syndrome (ACS) data are available in many hospitals and health units because ACS shows elevated morbidity and mortality. This work proposes a method called Data Science Analysis and Representation (DSAR) to scrutinize and exploit, in a univariate way, scientific information content in limited ACS samples. DSAR uses Bootstrap Resampling to provide robust, cross-sectional, and non-parametric statistical tests on categorical and metric variables. It also constructs an informative graphical representation of the database variables, which helps to interpret the results and to identify the relevant variables. Our objectives were to validate DSAR by comparing it to conventional statistical methods when looking for the most relevant variables in the secondary prevention of ACS, and to determine the degree of correlation between them and the Exitus event (associated with patient death). To achieve this objective, we applied DSAR on an anonymized sample of 270 variables from 2377 patients diagnosed with ACS. The results showed that DSAR identified 44% significant variables while conventional methods offered weak correlation results. Then, the scientific literature was reviewed for a set of these variables, validating the agreement with clinical experience and previous ACS research. The conclusion is that DSAR is a valuable and a useful method for clinicians in the identification of potentially predictive variables and, overall, a good starting point for future multivariate secondary analyzes in the clinical field of ACS, or fields with similar information characteristics.

Pericardial effusion (PCE) can be associated with Kawasaki disease (KD). We performed a multicenter, retrospective cohort study of the Pediatric Health Information System of children admitted with KD to determine the association between PCE and adverse outcomes. A total of 17 422 patients were in the cohort, of which 440 (3%) had PCE. PCE was associated with longer hospital length of stay (adjusted odds ratio [aOR] = 1.23; P < .01) and risk of readmission at 30 days (aOR = 1.42; P = .03). Black children were more likely to have a PCE (aOR = 1.54, P < .01) and longer length of stay (aOR = 1.05; P < .001). These data may support delayed discharge in children with PCE and KD in the hopes of preventing readmission. Special consideration needs to be given to how black children with KD are managed.

Objective We explore if there are ways to characterize health systems-not already revealed by secondary data-that could provide new insights into differences in health system performance. We sought to collect rich qualitative data to reveal whether and to what extent health systems vary in important ways across dimensions of structural, functional, and clinical integration. Data sources Interviews with 162 c-suite executives of 24 health systems in four states conducted through "virtual" site visits between 2017 and 2019. Study design Exploratory study using thematic comparative analysis to describe factors that may lead to high performance. Data collection We used maximum variation sampling to achieve diversity in size and performance. We conducted, transcribed, coded, and analyzed in-depth, semi-structured interviews with system executives, covering such topics as market context, health system origin, organizational structure, governance features, and relationship of health system to affiliated hospitals and POs. Principal findings Health systems vary widely in size and ownership type, complexity of organization and governance arrangements, and ability to take on risk. Structural, functional, and clinical integration vary across systems, with considerable activity around centralizing business functions, aligning financial incentives with physicians, establishing enterprise-wide EHR, and moving toward single signatory contracting. Executives describe clinical integration as more difficult to achieve, but essential. Studies that treat "health system" as a binary variable may be inappropriately aggregating for analysis health systems of very different types, at different degrees of maturity, and at different stages of structural, functional, and clinical integration. As a result, a "signal" indicating performance may be distorted by the "noise." Conclusions Developing ways to account for the complex structures of today's health systems can enhance future efforts to study systems as complex organizations, to assess their performance, and to better understand the effects of payment innovation, care redesign, and other reforms.

Objective To examine system integration with physician specialties across markets and the association between local system characteristics and their patterns of physician integration. Data sources Data come from the AHRQ Compendium of US Health Systems and IQVIA OneKey database. Study design We examined the change from 2016 to 2018 in the percentage of physicians in systems, focusing on primary care and the 10 most numerous nonhospital-based specialties across the 382 metropolitan statistical areas (MSAs) in the US. We also categorized systems by ownership, mission, and payment program participation and examined how those characteristics were related to their patterns of physician integration in 2018. Data collection/extraction methods We examined local healthcare markets (MSAs) and the hospitals and physicians that are part of integrated systems that operate in these markets. We characterized markets by hospital and insurer concentration and systems by type of ownership and by whether they have an academic medical center (AMC), a 340B hospital, or accountable care organization. Principal findings Between 2016 and 2018, system participation increased for primary care and the 10 other physician specialties we examined. In 2018, physicians in specialties associated with lucrative hospital services were the most commonly integrated with systems including hematology-oncology (57%), cardiology (55%), and general surgery (44%); however, rates varied substantially across markets. For most specialties, high market concentration by insurers and hospital-systems was associated with lower rates of physician integration. In addition, systems with AMCs and publicly owned systems more commonly affiliated with specialties unrelated to the physicians' potential contribution to hospital revenue, and investor-owned systems demonstrated more limited physician integration. Conclusions Variation in physician integration across markets and system characteristics reflects physician and systems' motivations. These integration strategies are associated with the financial interests of systems and other strategic goals (eg, medical education, and serving low-income populations).

Objectives The Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) item bank has been developed to standardize patient-reported PF across medical fields. However, evidence of scoring equivalence across cardiology and rheumatology patients is still missing. Therefore, this study aims to investigate both (1) the extent of disease-related differential item functioning (DIF) and (2) the impact of the disease group on using subdomain-specific item sets for generating PROMIS PF scores in cardiology and rheumatology patients. Study Design and Setting Ordinal regression was used to evaluate DIF between cardiology (n = 201) and rheumatology (n = 200) inpatients. To explore the disease-specific impact of PF subdomains on scoring, we compared scores derived from the full item bank with scores derived from subdomain-specific item sets for each disease group. Results DIF was detected in 18 items, predominately from the upper extremity subdomain. When upper extremity items were used, cardiology patients reached systematically higher scores than using the full item bank. Rheumatology patients scored substantially higher when mobility items were used. Conclusion Applying the PROMIS PF metric to disease-specific item sets including items from differing subdomains may lead to biased comparisons of PF levels across disease groups. Disease-specific item parameters should be provided for items showing DIF, and subdomain-related content balancing is recommended for scoring the generic PROMIS PF construct.

Some Arab countries have health information systems (HIS) in place but they lack well trained IT staff. Poor management and lack of appreciation of the importance of HIS are major barriers to development and adoption of HIS in Arab hospitals.This research is part of a survey carried out to determine health informatics (HI) use and to assess the training needs of health professionals in Jordan and Palestine.A survey was conducted in 2017 among employees in all health professions at 14 hospitals in Jordan and Palestine to assess their use of the HI system and to assess the HI skills needed in both countries.The majority of respondents reported that their hospital departments were employing computer systems to run services. More than half had received training in computer skills but also half said they needed specialized training in HI. Between 58.0% and 73.6% agreed that their hospitals provided the necessary support to operate HI systems. The vast majority (86.0%) of health professionals reported that they needed skills to monitor diagnosis and treatment, including access to clinical findings. Other skills needed included using shared hospital services (85.6%), using medical records (84.7%), managing electronic patient data (84.5%), using patient medical records to conduct clinical research (83.4%), and using tele-care services and technologies effectively (75.9%).Health professionals in Palestine and Jordan are in need of training in HI and therefore educational programmes in the area of HI are strongly recommended.نُظم المعلومات الصحية في الأردن وفلسطين: الحاجة إلى التدريب في مجال المعلوماتية الصحية.حسين جبارين، يوسف خضر، عادل الطويل.يوجد في بعض البلدان العربية نُظُم معلومات صحية قائمة، إلا أنها تفتقر إلى العاملين المدرَّبين تدريباً جيداً في مجال تكنولوجيا المعلومات. ويشكِّل سوء الإدارة وعدم تقدير أهمية نُظم المعلومات الصحية عوائق رئيسية أمام تطوير نُظم المعلومات الصحية واعتمادها في المستشفيات بالبلدان العربية.يمثّل هذا البحث جزءاً من مسحٍ أُجري لتحديد استخدام المعلوماتية الصحية، ولتقييم احتياجات تدريب المهنيين الصحيين في الأردن وفلسطين.أُجري مسح في عام 2017 للعاملين في جميع المهن الصحية في 14 مستشفى في الأردن وفلسطين لتقييم استخدامهم لنظم المعلومات الصحية وتقييم المهارات التي يحتاجون إليها في مجال المعلوماتية الصحية في كلا البلدَيْن.أفاد غالبية المستجيبين بأن أقسام المستشفيات التي يعملون فيها تستخدم نُظماً حاسوبية لتشغيل الخدمات. وقد تلقَّى أكثر من نصفهم تدريباً على مهارات الحاسوب، ولكن نصفهم أيضاً قالوا إنهم بحاجة إلى تدريبٍ متخصصٍ في مجال المعلوماتية الصحية. ووافق ما بين 58.0٪ و 73.6٪ على أن المستشفيات التي يعملون فيها قدَّمت الدعم اللازم لتشغيل نُظم المعلومات الصحية. وأفادت الغالبية العظمى (86.0٪) من المهنيين الصحيين أنهم يحتاجون إلى مهارات لرصد التشخيص والعلاج، بما في ذلك إتاحة النتائج السريرية. وشملت المهارات الأخرى اللازمة استخدام خدمات المستشفيات المشتركة (85.6٪)، واستخدام السجلات الطبية (84.7٪)، وإدارة بيانات المرضى الإلكترونية (84.5٪)، واستخدام السجلات الطبية للمرضى لإجراء البحوث السريرية (83.4٪)، واستخدام تكنولوجيات وخدمات الرعاية عن بُعد بفعالية (75.9٪).يحتاج المهنيون الصحيون في فلسطين والأردن إلى التدريب في مجال المعلوماتية الصحية، ولذلك يوصَ بشدة بتوفير برامج تعليمية في هذا المجال.Systèmes d'information sanitaire en Jordanie et en Palestine : nécessité d'une formation en informatique sanitaire.Certains pays arabes disposent de systèmes d’information sanitaire, mais ils manquent de personnel informatique bien formé. Une mauvaise gestion et un manque d'appréciation de l'importance des systèmes d'information sanitaire constituent des obstacles majeurs au développement et à l'adoption de ces systèmes dans les hôpitaux du monde arabe.La présente recherche fait partie d'une enquête menée pour déterminer l'utilisation de l'informatique sanitaire et pour évaluer les besoins de formation des professionnels de santé en Jordanie et en Palestine.En 2017, une enquête a été menée auprès des employés de toutes les professions de santé de 14 hôpitaux en Jordanie et en Palestine afin d’évaluer leur utilisation du système d’information sanitaire et de déterminer les compétences en informatique sanitaire nécessaires dans les deux pays.La majorité des répondants ont indiqué que leurs services hospitaliers utilisaient des systèmes informatiques pour gérer leurs services. Plus de la moitié a reçu une formation en informatique, mais la moitié a également déclaré avoir besoin d'une formation spécialisée en informatique sanitaire. Entre 58,0 % et 73,6 % ont convenu que leurs hôpitaux fournissaient le soutien nécessaire au fonctionnement des systèmes d'information sanitaire. La grande majorité (86,0 %) des professionnels de santé ont déclaré avoir besoin de compétences pour surveiller le diagnostic et le traitement, y compris l'accès aux résultats cliniques. Les autres compétences nécessaires comprenaient le recours aux services hospitaliers partagés (85,6 %), l'utilisation des dossiers médicaux (84,7 %), la gestion électronique des données des patients (84,5 %), l'utilisation des dossiers médicaux des patients pour mener des recherches cliniques (83,4 %) et l'utilisation efficace des services et des technologies de télésoins (75,9 %).Les professionnels de santé en Palestine et en Jordanie ont besoin d'une formation en informatique sanitaire. Par conséquent, des programmes d’éducation dans ce domaine sont fortement recommandés.

Resumo Introdução A Atenção Básica à Saúde, que integra a Rede de Atenção Psicossocial (RAPS), deve apresentar papel fundamental para a identificação de casos, acompanhamento e promoção da saúde mental, ações com as quais os Agentes Comunitários de Saúde (ACS) podem contribuir. Objetivo Analisar a situação de saúde mental do município de Itabuna-BA, comparando informações fornecidas por ACS e pelo Sistema de Informação em Saúde para a Atenção Básica (SISAB). Método Trata-se de pesquisa exploratória, descritiva, documental, que recuperou informações do SISAB e de Fichas de Cadastro da Coordenação de Saúde Mental, preenchidas por ACS. Resultados A participação dos ACS elevou em mais de seis vezes o número de pessoas com transtornos mentais identificadas, mas o número de usuários de álcool e outras substâncias foi inferior ao registrado no SISAB. Foram constatadas evidências de desarticulação da RAPS e modelo de atenção biologizante e hospitalocêntrico. Conclusão As fontes de informação se complementaram, evidenciando subnotificação dos casos de saúde mental e bom potencial dos ACS para auxiliar na busca ativa de usuários com transtorno mental, mas não de usuários de substâncias. Problemas de saúde mental relacionaram-se com aspectos de vulnerabilidade socioeconômica, indicando a necessidade de articulação intersetorial para oferecer atenção integral à saúde. ABSTRACT Background Primary Care Services is part of the Brazilian Psychosocial Care Network (PCN) and is expected to play a fundamental role in the identification of cases, monitoring and promotion of mental health, to which Community Health Agents (CHA) can contribute. Objective Analyze the mental health situation of the municipality of Itabuna - BA, compare information provided by CHAs and the Health Information System for Primary Care (SISAB). Method This was an exploratory, descriptive, documentary research that retrieved information from the SISAB and from Mental Health Coordination registry files, completed by CHAs. Results The participation of CHAs increased by more than six times the number of people with mental disorders identified, but the number of users of alcohol and other drugs was lower than that registered in SISAB. Conclusion There was evidence of PCN disarticulation and a model of biological and hospital-centered care. The sources of information complemented each other, evidencing underreport of mental health cases and good potential for CHAs assistance in the active search of users with mental disorders, but not of drug users. Mental health problems were related to aspects of socioeconomic vulnerability, indicating the need for intersectoral articulation to provide comprehensive health care.

ObjectiveTo assess the association between clinical integration and financial integration, quality-focused care delivery processes, and beneficiary utilization and outcomes.Data sourcesMultiphysician practices in the 2017-2018 National Survey of Healthcare Organizations and Systems (response rate 47%) and 2017 Medicare claims data.Study designCross-sectional study of Medicare beneficiaries attributed to physician practices, focusing on two domains of integration: clinical (coordination of patient services, use of protocols, individual clinician measures, access to information) and financial (financial management and planning across operating units). We examined the association between integration domains, the adoption of quality-focused care delivery processes, beneficiary utilization and health-related outcomes, and price-adjusted spending using linear regression adjusting for practice and beneficiary characteristics, weighting to account for sampling and nonresponse.Data collection/extraction methods1604580 fee-for-service Medicare beneficiaries aged 66 or older attributed to 2113 practices. Of these, 414209 beneficiaries were considered clinically complex (frailty or 2+chronic conditions).Principal findingsFinancial integration and clinical integration were weakly correlated (correlation coefficient=0.19). Clinical integration was associated with significantly greater adoption of quality-focused care delivery processes, while financial integration was associated with lower adoption of these processes. Integration was not generally associated with reduced utilization or better beneficiary-level health-related outcomes, but both clinical integration and financial integration were associated with lower spending in both the complex and noncomplex cohorts: (clinical complex cohort: -$2518, [95% CI: -3324, -1712]; clinical noncomplex cohort: -$255 [95% CI: -413, -97]; financial complex cohort: -$997 [95% CI: -$1320, -$679]; and financial noncomplex cohort: -$143 [95% CI: -210, -$76]).ConclusionsHigher levels of financial integration were not associated with improved care delivery or with better health-related beneficiary outcomes. Nonfinancial forms of integration deserve greater attention, as practices scoring high in clinical integration are more likely to adopt quality-focused care delivery processes and have greater associated reductions in spending in complex patients.

Background Nationally representative household surveys are the gold standard for tracking progress in coverage of life-saving maternal and child interventions, but often do not provide timely information on coverage at the local and health facility level. Electronic routine health information system (RHIS) data could help provide this information, but there are currently concerns about data quality. This analysis seeks to improve the usability of and confidence in electronic RHIS data by using adjustments to calculate more accurate numerators and denominators for essential interventions. Methods Data from three sources (Ugandan Demographic and Health (UDHS) survey, electronic RHIS, and census) were used to provide estimates of essential maternal (> 4 antenatal care visits (ANC), skilled delivery, and postnatal care visit (PNC)) and child health interventions (diphtheria, pertussis, tetanus, and hepatitis B and Haemophilus influenzae type b and polio vaccination series, measles vaccination, and vitamin A). Electronic RHIS data was checked for quality and both numerators and denominators were adjusted to improve accuracy. Estimates were compared between the three sources. Results Estimates of maternal health interventions from adjusted electronic RHIS data were lower than those of the UDHS, while child intervention estimates were typically higher. Adjustment of electronic RHIS data generally improved accuracy compared with no adjustment. There was considerable agreement between estimates from adjusted, electronic RHIS data, and UDHS for skilled delivery and first dose of childhood vaccination series, but lesser agreement for ANC visits and second and third doses of childhood vaccinations. Conclusions Nationally representative household surveys will likely continue being the gold standard of coverage estimates of maternal and child health interventions, but this analysis shows that current approaches to adjusting health facility estimate works better for some indications than others. Further efforts to improve accuracy of estimates from RHIS sources are needed.

With regard to the importance of health Information Governance (IG) programs in improving the quality and reducing the cost of healthcare services and the lack of a coherent health IG program in Iran’s health system, this study aimed to develop a model for national health information governance program in Iran. The present research was an applied, cross-sectional descriptive study that was done in three steps, including literature review, development of a model for national health IG program in Iran, and model validation. In the third step, we used a questioner to validate the model through the Delphi method. Data analysis was done by descriptive statistics. The model for the national IG program in Iran was developed in 3 main sections consisting of 13 components, 12 principles, natural and judicial authorities of the health IG program, and their job description. Findings from the validation of the initial model showed that most experts (93%) confirmed the components and sub-components, principles, and natural and legal bodies supervising the national health IG program and their job description in the proposed model. Considering the structure of the Iranian health system, it was recommended to establish a health IG council in the Ministry of Health and Medical Education in order to develop guidelines and give advice to health care providers. Based on the proposed model, directors and staff of different departments of health care centers, especially those involved in health IG, are also responsible for the better implementation of the national health IG program.

Highlights • The response to COVID-19 in LMICs is challenged by fragile health systems and poverty. • Expanded access to mobile phones facilitates their use in the COVID-19 response. • Mobile phone technology can improve case reporting and patient referral pathways. • We give examples of initiatives enhancing patient care and public health outcome. • We present a checklist for helpful mobile communication to combat COVID-19., Estimates of health capacities in the context of the 2019 coronavirus (COVID-19) pandemic indicate that most low- and middle-income countries (LMICs) are not operationally ready to manage this health emergency. Motivated by worldwide successes in other infectious disease epidemics and our experience in sub-Saharan Africa, we support mobile phone communication to improve data collection and reporting, communication between healthcare workers, public health institutions and patients and implementation of disease tracking and subsequent risk-stratified isolation measures. Programmatic action is needed for centrally coordinated reporting and communication systems facilitating mobile phones in crisis management plans for addressing the COVID-19 pandemic in LMICs. We summarize examples of worldwide mobile phone technology initiatives that enhanced patient care and public health outcome in previous epidemics and the current COVID-19 pandemic. In addition, we provide an overview of baseline conditions, including transparency about privacy guarantees, necessary for the successful use of mobile phones in assisting in the fight against COVID-19 spread.

Objectives Real-time relevant information helps guide the healthcare decision-making process in daily clinical practice as well as the management and optimization of healthcare processes. However, proprietary business intelligence suite solutions supporting the production of decision-making information requires investment that is out of reach of small and mediumsized healthcare facilities or those with limited resources, particularly in developing countries. This paper describes our experience in designing and implementing a real-time healthcare monitoring system solution to manage healthcare emergency units. Methods Through the use of free Business Intelligence tools and Python data science language we designed a real-time monitoring system, which was implemented to explore the Electronic Medical Records system of a university mental health emergency unit and render an electronic dashboard to support health professional daily practice. Results Three main dashboards were created to monitor patient waiting time, to access the clinical notes summary for the next waiting patient, and to obtain insights into activity during the last 24 hours. Conclusions The designed system could serve as a monitoring support model using free and user-friendly data science tools, which are good alternatives to proprietary business intelligence solutions and drastically reduce cost. Still, the key to success in decision-making systems is based on investment in human resources, business intelligence skills training, the organizational aspect of the decision-making process, and data production quality insurance.

Objective: Antibiotic overuse is one of the major prescription problems in rural China and a major risk factor for antibiotic resistance. Low antibiotic prescription rates can effectively reduce the risk of antibiotic resistance. We hypothesized that under a paperless, computer-based feedback system the rates of antibiotic prescriptions among primary care physicians can be reduced. Methods: A cluster randomized crossover open controlled trial was conducted in 31 hospitals. These hospitals were randomly allocated to two groups to receive the intervention for three months followed by no intervention for three months in a random sequence. The feedback intervention information, which displayed the physicians’ antibiotic prescription rates and ranking, was updated every 10 days. The primary outcome was the 10-day antibiotic prescription rate of the physicians. Results: There were 82 physicians in group 1 (intervention first followed by control) and 81 in group 2 (control first followed by intervention). Baseline comparison showed no significant difference in antibiotic prescription rate between the two groups (30.8% vs 35.2%, P-value = 0.07). At the crossover point, the relative reduction in antibiotic prescription rate was significantly higher among physicians in the intervention group than in the control group (33.1% vs 20.3%, P-value

Background One way to optimize the adoption and use of technological innovations is to understand how those involved perceive, assess and decide to use them. This study aims to analyze the attributes that influence the adoption and use of the Brazilian National Immunization Program Information System (NIPIS) from the perspective of vaccination room workers. Methods This is a mixed method research, and a quantitative cross-sectional analytical study, with concomitant triangulation of data, carried out in a region of Brazil by using the Diffusion of Innovation Theory. We used a questionnaire with 183 nursing professionals who work at vaccination rooms in 12 municipalities. To test the research model, partial least squares structural equation modeling (PLS-SEM) and SmartPLS 2.3.0 have been applied to estimate the model. The qualitative research had a descriptive-exploratory character, using interviews (n = 18) analyzed through thematic analysis. Results The model proposed showed a mean correlation between the perceived attributes in the adoption and use of NIPIS. The results of the multiple regression indicated that the attributes “relative advantage” and “image” have a significant effect at 5% level (T > 1.97), positively influence the adoption and use of NIPIS; the attribute “voluntary use” negatively influences the adoption and use of the system; the attributes “experimentation”, “compatibility”, “profitability”, and “ease of use” did not influence the adoption and use of NIPIS. Emphasis has been placed on aspects that weaken the adoption and use of NIPIS such as lack of good quality internet and resistance to use the technology by some professionals. Workers perceive the importance of NIPIS for the municipality and point out that technological innovation provides data at an individual level, inserted in real time, which makes it possible to assess vaccination coverage. Lack of an unstable internet compromises data release due to system slowness. Conclusions The mixed method allowed an in-depth analysis of the adoption and use of NIPIS in the Western Health Macroregion of Minas Gerais State, and similarities were observed in the results. The attribute “relative advantage” is the one that most influences the adoption and use of NIPIS, which is the strongest predictor of innovation adoption rate.

Background National health information (HI) systems provide data on population health, the determinants of health and health system performance within countries. The evaluation of these systems has traditionally focused on statistical practices and procedures, and not on data use or reuse for policy and practice. This limits the capacity to assess the impact of HI systems on healthcare provision, management and policy-making. On the other hand, the field of Knowledge Translation (KT) has developed frameworks to guide evidence into practice. Methods A scoping review of the KT literature to identify the essential mechanisms and determinants of KT that could help monitor the impact of HI systems. Results We examined 79 publications and we identified over 100 different KT frameworks but none of these were focused on HI systems per se. There were specific recommendations on disseminating evidence to stakeholders at the institutional and organizational level, and on sustaining the use of evidence in practice and the broader community setting. Conclusions We developed a new model, the HI-Impact framework, in which four domains are essential for mapping the impact of national HI systems: (i) HI Evidence Quality, (ii) HI System Responsiveness, (iii) Stakeholder Engagement and (iv) Knowledge Integration. A comprehensive impact assessment of HI systems requires addressing the use of HI in public health decision-making, health service delivery and in other sectors which might have not been considered previously. Monitoring Stakeholder Engagement and Knowledge Integration certifies that the use of HI in all policies is an explicit point of assessment.

Objective: To select the best papers that made original and high impact contributions in the area of human factors and organizational issues in biomedical informatics in 2019. Methods: A rigorous extraction process based on queries from Web of Science® and PubMed/Medline was conducted to identify the scientific contributions published in 2019 that address human factors and organizational issues in biomedical informatics. The screening of papers on titles and abstracts independently by the two editors led to a total of 30 papers. These papers were discussed for a selection of 15 finalist papers, which were then reviewed by the two editors and by three external reviewers from internationally renowned research teams. Results: The query process resulted in 626 papers that reveal interesting and rigorous methods and important studies in human factors that move the field forward, particularly in clinical informatics and emerging technologies such as brain-computer interfaces. This year three papers were clearly outstanding and help advance the field. They provide examples of applying existing frameworks together in novel and highly illuminating ways, showing the value of theory development in human factors. Conclusion: The selected papers make important contributions to human factors and organizational issues, expanding and deepening our knowledge of how to apply theory and applications of new technologies in health.

Background Routine health information systems (RHISs) support resource allocation and management decisions at all levels of the health system, as well as strategy development and policy-making in many low- and middle-income countries (LMICs). Although RHIS data represent a rich source of information, such data are currently underused for research purposes, largely due to concerns over data quality. Given that substantial investments have been made in strengthening RHISs in LMICs in recent years, and that there is a growing demand for more real-time data from researchers, this systematic review builds upon the existing literature to summarize the extent to which RHIS data have been used in peer-reviewed research publications. Methods Using terms ‘routine health information system’, ‘health information system’, or ‘health management information system’ and a list of LMICs, four electronic peer-review literature databases were searched from inception to February 202,019: PubMed, Scopus, EMBASE, and EconLit. Articles were assessed for inclusion based on pre-determined eligibility criteria and study characteristics were extracted from included articles using a piloted data extraction form. Results We identified 132 studies that met our inclusion criteria, originating in 37 different countries. Overall, the majority of the studies identified were from Sub-Saharan Africa and were published within the last 5 years. Malaria and maternal health were the most commonly studied health conditions, although a number of other health conditions and health services were also explored. Conclusions Our study identified an increasing use of RHIS data for research purposes, with many studies applying rigorous study designs and analytic methods to advance program evaluation, monitoring and assessing services, and epidemiological studies in LMICs. RHIS data represent an underused source of data and should be made more available and further embraced by the research community in LMIC health systems.

Background HIV diagnosis in South Africa is based on a point-of-care testing (PoCT) algorithm with paper-based record-keeping. Aggregated testing data are reported routinely. To facilitate improved HIV case-based surveillance, the Western Cape Province implemented a unique pilot intervention to digitise PoCT results, at an individual level, and generate an electronic register using the newly developed Provincial Health Data Centre (PHDC). We describe the intervention (phased) and present an evaluation of the operational feasibility of the intervention. We also offer implementation insights into establishing electronic capture of individual level testing data. Methods Cross-sectional analyses were conducted on records of all patients attending a local Community Health Centre who had an HIV-PoCT during the study period. Data from the intervention were linked to the PHDC using a unique identifier and compared with aggregate data from the paper-based register. Correlation coefficients were calculated to quantify the correlation between the two monthly datasets. To support an understanding of the findings, the Department of Health project management team generated reflections on the implementation process, which were then grouped thematically into implementation lessons. Results In total, 11,337 PoCT records were digitised (70% (7954) during Phase I; and 30% (3383) during Phase II). Linkage of forms to the PHDC was 96% in Phase I and 98% in Phase II. Comparison with aggregate data showed high correlation during Phase I, but notable divergence during Phase II. Divergence in Phase II was due to stringent data quality requirements and high clinical staff turnover. Factors supporting implementation success in Phase I included direct oversight of data capturing by a manager with clinical and operational insight. Implementation challenges included operational, health system, and high cost-related issues. Conclusions We demonstrate that rapid digitisation of HIV PoCT data, without compromising currently collected aggregate data, is operationally feasible, and can contribute to person-level longitudinal HIV case-based surveillance. To take to scale, we will need to improve PoCT platforms and clerical and administrative systems. Although we highlight challenges, we demonstrate that electronic HIV testing registers can successfully replace manual registers and improve efforts to monitor and evaluate HIV testing strategies.

Background: Our objective was to quantify trends in Emergency Medical Services (EMS) incidents as the effects of the COVID-19 pandemic spread across the United States, and to determine if there was an increase in EMS attended deaths. Methods: We conducted a three-year comparative retrospective cohort analysis of data from the National EMS Information System. Data were included if care was provided between the 40th and 21st week of the next year and compared over three-years. We included incidents identified through 9-1-1 where patient contact was made. The total number of EMS incidents per week was used as the denominator to calculate the rate of patient deaths and possible injury. We assessed for temporal and seasonal trends. Results: Starting in the 10th week of 2020 there was a decrease in the number of EMS activations in the United States compared to the prior weeks and the same time period in previous years. The number of activations between week 10 and 16 decreased by 140,292 or 26.1%. The portion of EMS activations reporting a patient disposition of death nearly doubled between the 11th and 15th week of 2020 (1.49% to 2.77% of all activations). The number of EMS activations documenting a possible injury decreased from 18.43% to 15.27% between weeks 10 and 13. Conclusion: We found that early in the COVID-19 outbreak there was a significant decrease in the number of EMS responses across the United States. Simultaneously the rate of EMS attended death doubled, while the rate of injuries decreased.

Background There is growing interest in the use of reliable evidence for health decision-making among low-and middle-income countries. Ghana has deployed DHIMS2 to replace the previously existing manual data harmonization processes. Methods This cross-sectional study was conducted in 12 districts comprising 12 district directorates, 10 district hospitals, 29 sub-district health centers, and 38 community health facilities in the Brong-Ahafo Region. Data collection tools were developed based on the Measure Evaluate assessment tools designed for evaluating the performance of routine information systems management tools. Utilization was assessed based on documented evidence and data was analyzed using STATA version 14. Results Although 93% of the health facilities studied submitted data unto the DHIMS2 platform, evidence suggested low use of this data in decision-making, particularly at the community level facilities where only 26% of the facilities used data from DHIMS2 to inform annual action plans and even less than 20% examined findings and issued directives for action. At the district level, 58% issued directives based on DHIMS2 information, 50% used DHIMS2 information for Advocacy purposes and 58% gave feedback reports based on DHIMS2 data for action. Functional computers were lacking across all facilities. Conclusions Activities relating to the use of DHIMS2 information skew towards data quality checking with less focus on examining findings, making comparisons, and taking action-based decisions from findings and comparisons. Improving factors like internet access, availability of functional ICTs, frequency of supervisory visits, staff training and the provision of training manuals may facilitate the use of DHIMS2 in decision-making at all levels of the district health system.

Purpose An injury surveillance information system (ISIS) collects, analyzes, and distributes data on injuries to promote health care delivery. The present study aimed to review the data elements and functional requirements of this system. Method This study was conducted in 2019. Studies related to injury surveillance system were searched from January 2000 to September 2019 via the databases of PubMed, Web of Knowledge, ScienceDirect, and Scopus. Articles related to the epidemiology of injury, population survey, and letters to the editor were excluded, while the review and research articles related to ISISs were included in the study. Initially 324 articles were identified, and finally 22 studies were selected for review. Having reviewed the articles, the data needed were extracted and the results were synthesized narratively. Results The results showed that most of the systems reviewed in this study used the minimum data set suggested by the World Health Organization injury surveillance guidelines along with supplementary data. The main functions considered for the system were injury track, data analysis, report, data linkage, electronic monitoring and data dissemination. Conclusion ISISs can help to improve healthcare planning and injury prevention. Since different countries have various technical and organizational infrastructures, it is essential to identify system requirements in different settings.

Communication is a core component of effective healthcare that impacts many patient and doctor outcomes, yet is complex and challenging to both analyse and teach. Human-based coding and audit systems are time-intensive and costly; thus, there is considerable interest in the application of artificial intelligence to this topic, through machine learning using both supervised and unsupervised learning algorithms. In this article we introduce health communication, its importance for patient and health professional outcomes, and the need for rigorous empirical data to support this field. We then discuss historical interaction coding systems and recent developments in applying artificial intelligence (AI) to automate such coding in the health setting. Finally, we discuss available evidence for the reliability and validity of AI coding, application of AI in training and audit of communication, as well as limitations and future directions in this field. In summary, recent advances in machine learning have allowed accurate textual transcription, and analysis of prosody, pauses, energy, intonation, emotion and communication style. Studies have established moderate to good reliability of machine learning algorithms, comparable with human coding (or better), and have identified some expected and unexpected associations between communication variables and patient satisfaction. Finally, application of artificial intelligence to communication skills training has been attempted, to provide audit and feedback, and through the use of avatars. This looks promising to provide confidential and easily accessible training, but may be best used as an adjunct to human-based training., Highlights • Artificial intelligence (AI) applied to health professional-patient communication enables efficient audit and feedback. • Very recent advances have increased the ability of AI to encode the complexity in human interaction. • AI can now encode words as well as a person does, as well as emotion and non-verbal aspects of communication. • AI coding has been shown to be moderately to substantially reliable. • Translation into the real world has yet to be demonstrated.

Integrated breast cancer care is complex, marked by multiple hand-offs between primary care and specialists over an extensive period of time. Communication is essential for treatment compliance, lowering error and complication risk, as well as handling co-morbidity. The director role of care, however, becomes often unclear, and patients remain lost across departments. Digital tools can add significant value to care communication but need clarity about the directives to perform in the care team. In effective breast cancer care, multidisciplinary team meetings can drive care planning, create directives and structured data collection. Subsequently, nurse navigators can take the director's role and become a pivotal determinant for patient care continuity. In the complexity of care, automated AI driven planning can facilitate their tasks, however, human intervention stays needed for psychosocial support and tackling unexpected urgency. Care allocation of patients across centres, is often still done by hand and phone demanding time due to overbooked agenda's and discontinuous system solutions limited by privacy rules and moreover, competition among providers. Collection of complete outcome information is limited to specific collaborative networks today. With data continuity over time, AI tools can facilitate both care allocation and risk prediction which may unveil non-compliance due to local scarce resources, distance and costs. Applied research is needed to bring AI modelling into clinical practice and drive well-coordinated, patient-centric cancer care in the complex web of modern healthcare today.

Objectives Skills to employ nursing informatics to promote the health of individuals is of such importance that it is considered a core competence. Although investments are made to increase the use of e-health, there is no full understanding of the usability of e-health for healthcare. This paper presents a current picture of how e-health and m-health are defined and used as well as the effects their usage may have on the intended target group. Methods Peer-reviewed open-access papers and grey literature that define e-health and m-health from PubMed, SpringerLink, and Google.com were randomized. A mixed method design with an inductive approach was employed. Open-source software were used for analysis. Results The overview includes 30 definitions of e-health and m-health, respectively. The definitions were thematised into 14 narrative themes. The results of the study, and primarily a three-level model, provide an understanding of how different types of e-health and m-health can be put into practice, and the effects or consequences of using them, which may be either positive or negative. Conclusions Mobility and flexibility is important for both m-health and e-health. Five keywords that characterize the definitions of e-health and m-health are "health", "mobile", "use", "information", and "technology". E-health or m-health cannot replace human actors because e-health and m-health consist of social and material interactions. Using e-health and m-health is, thus, about developing healthcare without compromising native relics.

Growing demand for use of Health Facility (HF) HIV testing data, in addition to other testing data to obtain district level HIV prevalence requires understanding the comparability of these various sources. We analysed the 2011 Uganda AIDS indicator survey data to assess: the proportion of people tested for HIV across Uganda by venue of testing; HIV prevalence ratio for those tested in a HF compared to those tested in community setting; [Katz, D., Baptista, J., Azen, S. P., & Pike, M. C. (1978). Obtaining confidence intervals for the risk ratio in cohort studies. International Biometric Society, 34(3), 469-474. https://doi.org/10.2307/2530610] and factors associated with HIV positivity in each subgroup. Of the 11,685 individuals, 8978 (77.1%) had ever tested for HIV in a HF. Fifty nine per cent tested in a HF in the 12 months preceding the survey (female: 5507, 72.7% versus male: 1413, 34.9%). HIV prevalence ratio was 1.8 times among those tested in a HF compared to those tested at community setting (10.9% [95% CI: 10.0-11.7] versus 6.2% [95% CI: 5.4-7.0]). Among HF testers, older age group, previously married and having no sexual partner was associated with significantly higher HIV prevalence. Using facility testing data for planning and decisions should take into consideration the elevated and varying HIV prevalence among individuals accessing HIV testing services at HFs as well as differences in their social-demographic characteristics.

The number of children receiving extracorporeal membrane oxygenation (ECMO) has increased substantially, and includes a growing population of children with complex underlying conditions who previously may not have been considered ECMO candidates. However, it remains unclear to what extent the underlying disease impacts the risk of death in these patients, particularly related to malignancy, bone marrow transplantation, complex congenital heart disease (CHD), or chromosomal abnormalities. A retrospective study was performed using the Pediatric Health Information System database of all children placed on ECMO more than a 10 year period between 2004 and 2013. Patients with diagnoses of bone marrow transplant, leukemia, lymphoma, neutropenia, immune system abnormalities, genetic abnormalities, neoplastic disorders, and complex CHD were selected as "high risk" and their outcomes were compared with overall outcomes. Extracorporeal membrane oxygenation was used in 9,194 children. Two thousand two hundred (24%) were identified as high risk. Bone marrow transplant (81% mortality; odds ratio [OR] 3.49), leukemia (66% mortality; OR 1.88), and neutropenia (58% mortality; OR 1.62) were associated with higher odds of mortality. Complex CHD (52% mortality) and genetic syndromes (48%) were not associated with higher mortality. These findings are pertinent for clinicians and families when considering ECMO candidacy in these children.

Objectives To assess the safety and efficacy in routine clinical practice of balloon dilatation procedures in the treatment of paediatric airway stenosis. Design Observational data collection in prospective online research database. Setting Acute NHS Trusts with ENT department undertaking complex paediatric airway work. Participants Children (

Background: nystagmus is a disorder of rhythmic, involuntary oscillations of the eyes and can be classified aseither infantile or acquired. Whether it occurs in isolation or as a part of other visual or neurological disorders, itcauses significant visual dysfunction and problems with social functioning. In this study, we seek to understandways in which people with nystagmus are currently supported across the UK and identify any geographicalvariations or disconnects between current practice and best practice, as judged by patients and their carers.Methods: a nationwide, qualitative, cross-sectional, questionnaire study of people with nystagmus andtheir carers. Recruitment was achieved through specialist clinics, charity events, online advertisementsand social media calls. Data was gathered using five, age-appropriate questionnaires which werecompleted and returned to the research team between November 2016 and August 2018.Results: 184 respondents were included (89 carers, 47 patients aged 4–10 years, 5 aged 11–14 years, 4aged 15–17 years and 39 > 18 years). Notably, respondents rated social media as the best source ofinformation they have received, even compared with face-to-face consultation with medical professionals. Additionally, only 33% of the respondents had been offered visual impairment support. Notably,patterns of clinical practice and patient experience emerged according to geographical location,particularly provision of initial information and ongoing VI support.Conclusions: this study highlights a significant variation in the support and information received bypeople in the UK with nystagmus. It also supports the role of charities and increasingly, social media inthe provision of patient information. The study also highlights the need for standardized guidelines forthe management of patients with nystagmus, particularly with regard to support and information.

Background Routine health information systems can provide near real-time data for malaria programme management, monitoring and evaluation, and surveillance. There are widespread concerns about the quality of the malaria data generated through routine information systems in many low-income countries. However, there has been little careful examination of micro-level practices of data collection which are central to the production of routine malaria data. Methods Drawing on fieldwork conducted in two malaria endemic sub-counties in Kenya, this study examined the processes and practices that shape routine malaria data generation at frontline health facilities. The study employed ethnographic methods—including observations, records review, and interviews—over 18-months in four frontline health facilities and two sub-county health records offices. Data were analysed using a thematic analysis approach. Results Malaria data generation was influenced by a range of factors including human resource shortages, tool design, and stock-out of data collection tools. Most of the challenges encountered by health workers in routine malaria data generation had their roots in wider system issues and at the national level where the framing of indicators and development of data collection tools takes place. In response to these challenges, health workers adopted various coping mechanisms such as informal task shifting and use of improvised tools. While these initiatives sustained the data collection process, they also had considerable implications for the data recorded and led to discrepancies in data that were recorded in primary registers. These discrepancies were concealed in aggregated monthly reports that were subsequently entered into the District Health Information Software 2. Conclusion Challenges to routine malaria data generation at frontline health facilities are not malaria or health information systems specific; they reflect wider health system weaknesses. Any interventions seeking to improve routine malaria data generation must look beyond just malaria or health information system initiatives and include consideration of the broader contextual factors that shape malaria data generation.

Background In developing countries, health information system (HIS) is experiencing more and more difficulties to produce quality data. The lack of reliable health related information makes it difficult to develop effective health policies. In order to understand the organization of HIS in African countries, we undertook a literature review. Methods Our study was conducted using the PubMed and Scopus bibliographic search engines. The inclusion criteria were: (i) all articles published between 2005 and 2019, (ii) articles including in their title the keywords "health", "information", "systems", "system", "africa", "developing countries", "santé", "pays en développement", "Afrique", (iii) articles that are written in English or French, (iv) which deals with organizational and technical issues about HIS in African countries. Results Fourteen retrieved articles out of 2492 were included in the study, of which 13 (92.9%) were qualitative. All of them dealt with issues related to HIS in 12 African countries. All 12 countries (100.0%) had opted for a data warehouse approach to improve their HIS. This approach, supported by the DHIS2 system, has enabled providing reliable data. However, 11 out of the 12 countries (92.0%) frameworks were aligned with funding donors’ strategies and lacked any national strategy. Conclusion This study suggests that the lack of a national health information management strategy will always be a threat to HIS performance in African countries. Ideally, rigorous upstream thinking to strengthen HIS governance should be undertaken by defining and proposing a coherent conceptual framework to analyze and guide the development and integration of digital applications into HIS over the long term.

IntroductionFront-line health workers in remote health facilities are the first contact of the formal health sector and are confronted with life-saving decisions. Health information systems (HIS) support the collection and use of health related data. However, HIS focus on reporting and are unfit to support decisions. Since data tools are paper-based in most primary healthcare settings, we have produced an innovative Paper-based Health Information System in Comprehensive Care (PHISICC) using a human-centred design approach. We are carrying out a cluster randomised controlled trial in three African countries to assess the effects of PHISICC compared with the current systems.Methods and analysisStudy areas are in rural zones of Côte d’Ivoire, Mozambique and Nigeria. Seventy health facilities in each country have been randomly allocated to using PHISICC tools or to continuing to use the regular HIS tools. We have randomly selected households in the catchment areas of each health facility to collect outcomes’ data (household surveys have been carried out in two of the three countries and the end-line data collection is planned for mid-2021). Primary outcomes include data quality and use, coverage of health services and health workers satisfaction; secondary outcomes are additional data quality and use parameters, childhood mortality and additional health workers and clients experience with the system. Just prior to the implementation of the trial, we had to relocate the study site in Mozambique due to unforeseen logistical issues. The effects of the intervention will be estimated using regression models and accounting for clustering using random effects.Ethics and disseminationEthics committees in Côte d’Ivoire, Mozambique and Nigeria approved the trials. We plan to disseminate our findings, data and research materials among researchers and policy-makers. We aim at having our findings included in systematic reviews on health systems interventions and future guidance development on HIS.Trial registration numberPACTR201904664660639; Pre-results.

BackgroundThe use of digital technology in healthcare promises to improve quality of care and reduce costs over time. This promise will be difficult to attain without interoperability: facilitating seamless health information exchange between the deployed digital health information systems (HIS).ObjectiveTo determine the maturity readiness of the interoperability capacity of Kenya’s HIS.MethodsWe used the HIS Interoperability Maturity Toolkit, developed by MEASURE Evaluation and the Health Data Collaborative’s Digital Health and Interoperability Working Group. The assessment was undertaken by eHealth stakeholder representatives primarily from the Ministry of Health’s Digital Health Technical Working Group. The toolkit focused on three major domains: leadership and governance, human resources and technology.ResultsMost domains are at the lowest two levels of maturity: nascent or emerging. At the nascent level, HIS activities happen by chance or represent isolated, ad hoc efforts. An emerging maturity level characterises a system with defined HIS processes and structures. However, such processes are not systematically documented and lack ongoing monitoring mechanisms.ConclusionNone of the domains had a maturity level greater than level 2 (emerging). The subdomains of governance structures for HIS, defined national enterprise architecture for HIS, defined technical standards for data exchange, nationwide communication network infrastructure, and capacity for operations and maintenance of hardware attained higher maturity levels. These findings are similar to those from interoperability maturity assessments done in Ghana and Uganda.

Background Digital health interventions (DHIs) can alleviate several barriers to achieving better maternal and child health. The World Health Organization’s guideline recommendations for DHIs emphasize the need to integrate multiple DHIs for maximizing impact. The complex health system of Bangladesh provides a unique setting for evaluating and understanding the role of an electronic registry (eRegistry) for antenatal care, with multiple integrated DHIs for strengthening the health system as well as improving the quality and utilization of the public health care system. Objective The aim of this study is to assess the effect of an eRegistry with DHIs compared with a simple digital data entry tool without DHIs in the community and frontline health facilities. Methods The eRegMat is a cluster-randomized controlled trial conducted in the Matlab North and Matlab South subdistricts in the Chandpur district, Bangladesh, where health facilities are currently using the eRegistry for digital tracking of the health status of pregnant women longitudinally. The intervention arm received 3 superimposed data-driven DHIs: health worker clinical decision support, health worker feedback dashboards with action items, and targeted client communication to pregnant women. The primary outcomes are appropriate screening as well as management of hypertension during pregnancy and timely antenatal care attendance. The secondary outcomes include morbidity and mortality in the perinatal period as well as timely first antenatal care visit; successful referrals for anemia, diabetes, or hypertension during pregnancy; and facility delivery. Results The eRegistry and DHIs were co-designed with end users between 2016 and 2018. The eRegistry was implemented in the study area in July 2018. Recruitment for the trial started in October 2018 and ended in June 2020, followed by an 8-month follow-up period to capture outcome data until February 2021. Trial results will be available for publication in June 2021. Conclusions This trial allows the simultaneous assessment of multiple integrated DHIs for strengthening the health system and aims to provide evidence for its implementation. The study design and outcomes are geared toward informing the living review process of the guidelines for implementing DHIs. Trial Registration ISRCTN Registry ISRCTN69491836; https://www.isrctn.com/ISRCTN69491836 International Registered Report Identifier (IRRID) DERR1-10.2196/26918

Background New technology adoption is common in health care, but it may elicit frustration if end users are not sufficiently considered in their design or trained in their use. These frustrations may contribute to burnout. Objective This study aimed to evaluate and quantify health care workers’ frustration with technology and its relationship with emotional exhaustion, after controlling for measures of work-life integration that may indicate excessive job demands. Methods This was a cross-sectional, observational study of health care workers across 31 Michigan hospitals. We used the Safety, Communication, Operational Reliability, and Engagement (SCORE) survey to measure work-life integration and emotional exhaustion among the survey respondents. We used mixed-effects hierarchical linear regression to evaluate the relationship among frustration with technology, other components of work-life integration, and emotional exhaustion, with adjustment for unit and health care worker characteristics. Results Of 15,505 respondents, 5065 (32.7%) reported that they experienced frustration with technology on at least 3-5 days per week. Frustration with technology was associated with higher scores for the composite Emotional Exhaustion scale (r=0.35, P Conclusions This study found that frustration with technology and several other markers of work-life integration are independently associated with emotional exhaustion among health care workers. Frustration with technology is common but not ubiquitous among health care workers, and it is one of several work-life integration factors associated with emotional exhaustion. Minimizing frustration with health care technology may be an effective approach in reducing burnout among health care workers.

Resumo: O estudo objetivou analisar a adoção e o uso do e-SUS Atenção Primária (e-SUS APS) como inovação tecnológica na perspectiva dos profissionais da atenção primária à saúde (APS). Trata-se de um estudo de método misto explanatório sequencial (QUAN → qual) realizado em municípios do interior de São Paulo, Brasil, utilizando a Teoria da Difusão de Inovação. O estudo quantitativo foi do tipo transversal analítico, aplicando-se um questionário validado a 114 profissionais da APS. Para testar o modelo do estudo, aplicou-se a modelagem de equações estruturais de mínimos quadrados parciais (PLS-SEM) por meio do software SmartPLS 2.3.0. O estudo qualitativo teve caráter descritivo-exploratório, por meio de entrevistas (n = 10) analisadas por análise temática de conteúdo, visando entender os atributos que não influenciaram a adoção e o uso do e-SUS APS. Os atributos “experimentação”, “facilidade de uso”, “vantagem relativa” e “compatibilidade” não apresentaram significância estatística, indicando não serem atributos determinantes para adoção e uso do e-SUS APS. Na integração dos dados, evidenciaram-se: falhas de conectividade; ausência de tempo para alimentação do sistema em tempo real e de capacitação; não experimentação prévia; apresentação abrupta do sistema e ausência de habilidade com a tecnologia. Os resultados podem auxiliar os demais municípios do Brasil na implantação e/ou efetivação do e-SUS APS, no que tange à importância da infraestrutura organizacional, bem como na capacitação para utilização e manuseio da tecnologia. Este estudo contribui para reflexões e propostas de intervenções aos problemas enfrentados no cotidiano do trabalho quanto à adoção e ao uso de uma inovação tecnológica, como o e-SUS APS. Abstract: The study aimed to analyze the adoption and use of the Primary Healthcare e-SUS (PHC e-SUS) as a technological innovation from the perspective of workers in primary healthcare (PHC). This was a sequential exploratory mixed-methods study (QUAN → qual) in municipalities in the interior of São Paulo state, Brazil, drawing on Diffusion of Innovation Theory. The quantitative component was analytical cross-sectional, applying a validated questionnaire to 114 PHC workers. The model was tested by applying partial least squares structural equation modeling (PLS-SEM) using SmartPLS 2.3.0. The qualitative study was descriptive-exploratory, using interviews (n = 10) with thematic content analysis, aimed at understanding the attributes that did not influence the adoption and use of PHC e-SUS. The attributes “experimentation”, “ease of use”, “relative advantage”, and “compatibility” did not display statistical significance, indicating that they were not determinant attributes for the adoption and use of PHC e-SUS. Integration of the data evidenced failures in connectivity; lack of time to feed the system in real time and training; lack of prior experimentation; abrupt presentation of the system; and lack of skill with the technology. The results can assist other municipalities in Brazil with the implementation of the PHC e-SUS in relation to the importance of the organizational infrastructure, as well as training in the technology’s use and handling. The study contributes to reflections and proposals for interventions in the problems faced in daily work with the adoption and use of a technological innovation such as the PHC e-SUS. Resumen: El objetivo del estudio fue analizar la adopción y uso del e-SUS Atención Primaria (e-SUS APS), como innovación tecnológica, desde la perspectiva de los profesionales de la atención primaria en salud (APS). Se trata de un estudio de método mixto secuencial explicativo (CUAN → Cual) realizado en municipios del interior de São Paulo, utilizando la Teoría de la Difusión de Innovación. El estudio cuantitativo fue de tipo transversal analítico, aplicándose un cuestionario validado a 114 profesionales de la APS. Para probar el modelo del estudio se aplicó el modelado de ecuaciones estructurales de mínimos cuadrados parciales (PLS-SEM), a través del software SmartPLS 2.3.0. El estudio cualitativo tuvo carácter descriptivo-exploratorio, mediante entrevistas (n = 10), analizadas por análisis de contenido temático, con el objetivo de entender los atributos que no influenciaron en la adopción y uso de la e-SUS APS. Los atributos “probar”, “facilidad de uso”, “ventaja relativa” y “compatibilidad” no presentaron significación estadística, indicando no ser atributos determinantes para la adopción y uso de la e-SUS APS. En la integración de los datos se evidenciaron: fallos de conectividad; ausencia de tiempo para alimentación del sistema en tiempo real y de capacitación; no pruebas previas; presentación abrupta del sistema y ausencia de habilidad con la tecnología. Los resultados pueden ayudar a los demás municipios de Brasil en la implantación y/o efectuación de la e-SUS APS, en lo que atañe a la importancia de la infraestructura organizativa, así como la capacitación para la utilización y manejo de la tecnología. Este estudio contribuye a las reflexiones y propuestas de intervenciones, respecto a los problemas enfrentados en el día a día del trabajo, en cuanto a la adopción y uso de una innovación tecnológica, como la e-SUS APS.

Background Increasing the performance of routine health information systems (RHIS) is an important policy priority both globally and in Senegal. As RHIS data become increasingly important in driving decision-making in Senegal, it is imperative to understand the factors that determine their use. Methods Semi-structured interviews were conducted with 18 high- and mid-level key informants active in the malaria, tuberculosis and HIV programmatic areas in Senegal. Key informants were employed in the relevant divisions of the Senegal Ministry of Health or nongovernmental / civil society organizations. We asked respondents questions related to the flow, quality and use of RHIS data in their organizations. A framework approach was used to analyze the qualitative data. Results Although the respondents worked at the strategic levels of their respective organizations, they consistently indicated that data quality and data use issues began at the operational level of the health system before the data made its way to the central level. We classify the main identified barriers and facilitators to the use of routine data into six categories and attempt to describe their interrelated nature. We find that data quality is a central and direct determinant of RHIS data use. We report that a number of upstream factors in the Senegal context interact to influence the quality of routine data produced. We identify the sociopolitical, financial and system design determinants of RHIS data collection, dissemination and use. We also discuss the organizational and infrastructural factors that influence the use of RHIS data. Conclusions We recommend specific prescriptive actions with potential to improve RHIS performance in Senegal, the quality of the data produced and their use. These actions include addressing sociopolitical factors that often interrupt RHIS functioning in Senegal, supporting and motivating staff that maintain RHIS data systems as well as ensuring RHIS data completeness and representativeness. We argue for improved coordination between the various stakeholders in order to streamline RHIS data processes and improve transparency. Finally, we recommend the promotion of a sustained culture of data quality assessment and use.

Background With the 40th anniversary of the Declaration of Alma-Ata, a global effort is underway to re-focus on strengthening primary health care systems, with emphasis on leveraging community health workers (CHWs) towards the goal of achieving universal health coverage for all. Institutionalizing effective, sustainable community health systems is currently limited by a lack of standard metrics for measuring CHW performance and the systems they work within. Developed through iterative consultations, supported by the Bill & Melinda Gates Foundation and in partnership with USAID and UNICEF, this paper details a framework, list of indicators, and measurement considerations for monitoring CHW performance in low- and middle-income countries. Methods A review of peer-reviewed articles, reports, and global data collection tools was conducted to identify key measurement domains in monitoring CHW performance. Three consultations were successively convened with global stakeholders, community health implementers, advocates, measurement experts, and Ministry of Health representatives using a modified Delphi approach to build consensus on priority indicators. During this process, a structured, web-based survey was administered to identify the importance and value of specific measurement domains, sub-domains, and indicators determined through the literature reviews and initial stakeholder consultations. Indicators with more than 75% support from participants were further refined with expert qualitative input. Results Twenty-one sub-domains for measurement were identified including measurement of incentives for CHWs, supervision and performance appraisal, data use, data reporting, service delivery, quality of services, CHW absenteeism and attrition, community use of services, experience of services, referral/counter-referral, credibility/trust, and programmatic costs. Forty-six indicators were agreed upon to measure the sub-domains. In the absence of complete population enumeration and digitized health information systems, the quality of metrics to monitor CHW programs is limited. Conclusions Better data collection approaches at the community level are needed to strengthen management of CHW programs and community health systems. The proposed list of metrics balances exhaustive and pragmatic measurement of CHW performance within primary healthcare systems. Adoption of the proposed framework and associated indicators by CHW program implementors may improve programmatic effectiveness, strengthen their accountability to national community health systems, drive programmatic quality improvement, and plausibly improve the impact of these programs.

Anna Maria Bargagli, Silvia Cascini, Nera Agabiti, Ursula Kirchmayer, Claudia Marino, Marina Davoli Department of Epidemiology, Regional Health Service Lazio Region, Rome, ItalyCorrespondence: Silvia CasciniDepartment of Epidemiology, Regional Health Service Lazio Region, Via Cristoforo Colombo, Rome 112 - 00147, ItalyTel +39 06 9972 2130Fax +39 06 9972 2111Email s.cascini@deplazio.itIntroduction: Despite recommendations from associations of geriatric and psychiatry societies and warnings from drug agencies, antipsychotic (AP) drugs are frequently used to control behavioral and psychological symptoms of dementia. APs are associated with a range of potential adverse events, including increased risk of cerebrovascular events and mortality. Evidence suggests limited efficacy of APs for aggression and psychosis. Our objectives were to investigate patterns and predictors for prescription of APs among older adults with dementia residing in a large region of central Italy, and to identify patient characteristics related to typical or atypical APs prescribing.Methods: This is a retrospective population-based cohort study using data from regional health information systems (HIS). We included dementia patients aged ≥65 years residing in the Lazio region. The exposure was defined as new use vs non-use of APs. Dementia patients with incident use of APs during 2015 were followed-up from the date of first prescription to the earliest among discontinuation of use, death, or end of study (December 31, 2016).Results: We enrolled 24,735 dementia patients, 1727 (6.7%) new users and 23,008 non-users of APs. Forty-four percent of AP users were treated for more than 3 months, and among these about 60% received APs continuously for at least 12 months. Individuals using antidepressant or anti-dementia drugs had higher odds of being prescribed with APs (OR: 1.67 and OR: 1.86, respectively). Patients exposed to polypharmacy were less likely to receive APs (OR: 0.82). Cardiovascular risk factors and comorbidities were not associated with APs use. Low socio-economic position was associated with lower odds of atypical AP prescribing (OR: 0.57).Conclusion: The study showed that a not negligible proportion of patients had a period of AP use longer than recommended by guidelines. We identified socio-demographic and clinical factors associated with first use of APs, providing insight into prescribing practices in a community setting and useful information to address areas of potential inappropriateness.Keywords: dementia, antipsychotics, health information systems, older adults