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Background A decade after the Health Information Technology for Economic and Clinical Health (HITECH) Act, electronic health records (EHRs) largely remain poorly designed and contribute to clinician burnout. Objective The purpose of this study was to understand clinicians’ wants, needs, and perceived barriers imposed by the EHR; implement best practices in user-centered design; and create a clinician-centered EHR framework validated via a functional EHR prototype. Methods Usability evaluations were performed using a simulated patient with a complex clinical scenario. Convergent parallel mixed methods linked to action research and agile development were used to create an EHR prototype based on clinician-centered design. Prototype functionality was validated via a final usability evaluation. Results Between 2015 and 2017, 53 clinicians from 8 cardiology practices (4 academic and 4 private) participated in initial evaluations of their installed EHR. In 2019, 25 clinicians participated in final evaluations of their EHR vs our EHR prototype. Initial evaluations documented that clinicians judged the EHRs as poorly designed, scoring a mean of 47.1 on the System Usability Scale. Clinicians expressed that EHRs impeded workflow and communication and prolonged their workday. In the final evaluations, no improvement in installed EHRs was found (mean score 48.1); however, the EHR prototype was assessed as significantly more usable (mean score 77.8; P Conclusion A decade after the HITECH Act, EHRs still receive low usability scores. By applying user-centered design, an EHR prototype with improved features, functionality, and workflow integration was developed. Clinician testing of the EHR prototype demonstrated it was significantly more useful and usable to clinicians, thus identifying a framework and pathway for substantive improvement of EHR systems.

While personal health records (PHRs) carry an array of potential benefits such as increased patient engagement, poor usability remains a significant barrier to patients’ adoption of PHRs. In this mixed-methods study, we evaluate the usability of an important PHR feature, a patient intake form called the pre-visit summary, from the perspective of cognitive load using real cardiovascular patients in vivo. A validated measure for cognitive load, the NASA Task Load Index, was used along with retrospective interviews to identify tasks within the pre-visit summary that were more mentally challenging for patients. Participants experienced higher cognitive load on the Medications, Immunizations, Active Health Concerns, and Family History pages because these pages required a higher recall of personal health information and due to some user interface design issues. This research is significant because it uses validated measures of cognitive load to study real patients interacting with a PHR in vivo.

Background/Introduction Obesity and atrial fibrillation (AF) coexist and share multiple cardiovascular risk factors. Lifestyle modifications can reduce AF burden in obese patients. However, the time invested in pursing lifestyle changes may delay AF ablation, which could negate the procedural benefit. Purpose To examine the effects of lifestyle modifications and the timing of catheter ablation on morbidly obese patients with AF. Methods This retrospective study included 217 consecutive AF patients with a body mass index (BMI) ≥35 kg/m2 undergoing AF ablation at a tertiary care center from 2012 to 2019. Modifiable risks were examined, including the time from AF diagnosis to ablation, fluctuation of BMI >5% or an increase in BMI >3% prior to ablation, mean systolic blood pressure >130 mmHg or diastolic blood pressure >80 mmHg, obstructive sleep apnea with CPAP noncompliance, hyperlipidemia without statin therapy, tobacco use, excessive alcohol use, and diabetes mellitus with hemoglobin A1c (HbA1c) ≥6.5%. The primary outcome was a composite of recurrent atrial arrhythmias and cardiovascular (CV) hospitalizations following AF ablation. A multivariate analysis adjusting for age, gender and modifiable risks was performed. Results The mean age was 61±9 years old, 58% were female and 45% had persistent AF. A substantial portion of the study patients had modifiable risk factors, ranging from 2.7% with excessive alcohol use to 67.3% experiencing delayed AF ablation, Figure 1. The median time from diagnosed AF to ablation was 1.3 years. During a mean follow-up of 2.9 years after AF ablation, 136 (62.7%) patients met the primary outcome. Only HbA1c ≥6.5% was an independent risk factor with adjusted hazard ratio of 1.57, 95% confidence interval 1.02–2.36, P=0.0412, Figure 2A. Delayed AF ablation did not alter the outcome, Figure 2B. There was no interaction between time of ablation and HbA1c ≥6.5% (P=0.67). Conclusion Substantial portions of morbidly obese patients undergoing AF ablation have potentially modifiable risk factors. Poor glycemic control with HbA1c ≥6.5% predicts an increased risk of recurrent atrial arrhythmias and CV hospitalizations, while delayed AF ablation does not. This finding underscores an importance of optimizing HbA1c in morbidly obese patients with AF to reduce adverse outcomes after ablation. Funding Acknowledgement Type of funding sources: None.

Gregg C. Fonarow, MD, FACC, FAHA, Chair [∗][1] Biykem Bozkurt, MD, PhD, FACC[∗][1] Sandeep Das, MD, MPH[∗][1] Michael E. Hall, MD, MS, FAHA, FACC[∗][1] Hani Jneid, MD, FACC, FAHA[∗][1] Corrine Y. Jurgens, PhD, RN, ANP-BC, FAHA[∗][1],[†][2] Patricia Keegan, DNP, APRN, NP-C[‡][3

Funding Acknowledgements Type of funding sources: None. Introduction Obesity and extreme obesity increase risk of recurrent atrial fibrillation (AF) and perioperative complications following AF ablation. However, long-term outcomes following AF ablation among obese patients is unknown. Purpose To examine long-term cardiovascular (CV) mortality and hospitalization among obese patients undergoing AF ablation Methods This retrospective study included 830 consecutive patients undergoing AF ablation from January 2013 to June 2019 at a tertiary referral medical center. Patients with obesity defined as body mass index (BMI) ≥30-39.9 kg/m2 and a subgroup of patients with extreme obesity with BMI ≥40 kg/m2 were identified. Patients were monitored for mortality and hospitalization during a median follow-up time of 819 days. Multivariate model adjusting for CHA2DS2-VASc score and history of obstructive sleep apnea (OSA) was performed. Results Mean age was 62 ± 10 years and 67.5% were male. Obese patients (n = 493, 59%) had a higher CHA2DS2-VASc score, and greater prevalence of OSA. These patients tended to have higher all-cause mortality and hospitalization (adjusted HR, 1.21 95% CI 0.98 to 1.51; P = 0.078), as well as greater non-CV outcomes (adjusted HR 1.45, 95% CI 1.02 to 2.08; P = 0.04). However, CV death and admission were comparable among patients with and without obesity (adjusted HR 1.14, 95% CI 0.90 to 1.45; P = 0.28). A subgroup of 111 (13.4%) extremely obese patients were identified. In comparison with obese patients with BMI ≥30-39.9 kg/m2, patients with extreme obesity with BMI ≥40 kg/m2 had similar CV (adjusted HR 1.07, 95% CI 0.75 to 1.50; P = 0.70) and non-CV adverse outcomes (adjusted HR 1.11, 95% CI 0.69 to 1.72; P = 0.65), Figure. Conclusions Obesity is not associated with increased CV mortality or admission following AF ablation. Non-CV events are the major cause of adverse outcomes among obese patients. Identification and reversal, where possible, of non-CV comorbidity may result in improved long-term outcomes following AF ablation. In addition, extremely obese patients with BMI≥40 kg/m2 pose a similar risk of having adverse outcomes to obese patients with BMI≥30-39.9 kg/m2. Thus, patients with extreme obesity should not be excluded from catheter ablation as a management option of AF based solely on their BMI. Abstract Figure. Cumulative-Incidence Curves

Little is known at the local level how mHealth interventions support consumers’ goal of a healthy lifestyle and the impact of mHealth interventions on providing equitable care. This paper investigates: 1) the social determinants of health (SDOH) that affect the ability of people to be healthy and 2) clinicians use of mHealth interventions to facilitate equitable provision of healthcare. Socioeconomic and health data was collected from all 93 Nebraska counties. A positive correlation was found between the ability of people to be healthy and their access to health insurance and fresh food. A correlation was also discovered between poverty and the ability of people to be healthy and access food. A mobile app was then developed to provide information on available community resources for patients of a student-run free clinic. The contribution of this study is determining how mHealth can be used as a sustainable health equity intervention.

BACKGROUND In the era of precision medicine, it is critical for health communication efforts to prioritize personal health record (PHR) adoption. OBJECTIVE The objective of this study was to describe the characteristics of patients with heart disease that choose to adopt a PHR. METHODS A total of 79 patients with chronic cardiovascular disease participated in this study: 48 PHR users and 31 nonusers. They completed 5 surveys related to their choice to use or not use the PHR: demographics, patient activation, medication adherence, health literacy, and computer self-efficacy (CSE). RESULTS There was a significant difference between users and nonusers in the sociodemographic measure education (P=.04). There was no significant difference between users and nonusers in other sociodemographic measures: age (P=.20), sex (P=.35), ethnicity (P=.43), race (P=.42), and employment (P=.63). There was a significant difference between PHR users and PHR nonusers in CSE (P=.006). CONCLUSIONS In this study, we demonstrate that sociodemographic characteristics were not an important factor in patients’ use of their PHR, except for education. This study had a small sample size and may not have been large enough to detect differences between groups. Our results did demonstrate that there is a difference between PHR users and nonusers related to their CSE. This work suggests that incorporating CSE into the design of PHRs is critical. The design of patient-facing tools must take into account patients’ preferences and abilities when developing effective user-friendly health information technologies.

Background In the era of precision medicine, it is critical for health communication efforts to prioritize personal health record (PHR) adoption. Objective The objective of this study was to describe the characteristics of patients with heart disease that choose to adopt a PHR. Methods A total of 79 patients with chronic cardiovascular disease participated in this study: 48 PHR users and 31 nonusers. They completed 5 surveys related to their choice to use or not use the PHR: demographics, patient activation, medication adherence, health literacy, and computer self-efficacy (CSE). Results There was a significant difference between users and nonusers in the sociodemographic measure education (P=.04). There was no significant difference between users and nonusers in other sociodemographic measures: age (P=.20), sex (P=.35), ethnicity (P=.43), race (P=.42), and employment (P=.63). There was a significant difference between PHR users and PHR nonusers in CSE (P=.006). Conclusions In this study, we demonstrate that sociodemographic characteristics were not an important factor in patients’ use of their PHR, except for education. This study had a small sample size and may not have been large enough to detect differences between groups. Our results did demonstrate that there is a difference between PHR users and nonusers related to their CSE. This work suggests that incorporating CSE into the design of PHRs is critical. The design of patient-facing tools must take into account patients’ preferences and abilities when developing effective user-friendly health information technologies.

Background: To assess the current state of clinical data interoperability, we evaluated the use of data standards across 38 large professional society registries. Methods: The analysis included 4 primary components: 1) environmental scan, 2) abstraction and cross-tabulation of clinical concepts and corresponding data elements from registry case report forms, dictionaries, and / or data models, 3) cross-tabulation of same across national common data models, and 4) specifying data element metadata to achieve native data interoperability. Results: The registry analysis identified approximately 50 core clinical concepts. None were captured using the same data representation across all registries, and there was little implementation of data standards. To improve technical implementation, we specified 13 key metadata for each concept to be used to achieve data consistency. Conclusion: The registry community has not benefitted from and does not contribute to interoperability efforts. A common, authoritative process to specify and implement common data elements is greatly needed.

In 2018, the Task Force convened the writing committee to begin the process of revising the existing performance measures set for hypertension that had been released in 2011.3 The writing committee also was charged with the task of developing new measures to evaluate the care of patients in accordance with the 2017 Hypertension Clinical Practice Guidelines.4 The writing committee developed a comprehensive measure set for the diagnosis and treatment of high blood pressure (HBP) that includes 22 new measures: 6 performance measures, 6 process quality measures, and 10 structural quality measures. In conceptualizing these measures, the writing committee paid very close attention to the current Class of Recommendation (COR) and Level of Evidence (LOE) guideline classification scheme used by ACC and AHA in all of its guidelines, as shown in Table 1. Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated August 2015)*

BACKGROUND Identifying effective means of communication between patients and their health care providers has a positive impact on patients’ satisfaction, adherence, and health-related outcomes. OBJECTIVE This study aimed to identify the impact of patients’ age on their communication and technology preferences when managing their health. We hypothesize that a patient’s age affects their communication and technology preferences when interacting with clinicians and managing their health. METHODS A mixed methods study was conducted to identify the preferences of patients with cardiovascular diseases. Results were analyzed based on the patients’ age. Grounded theory was used to analyze the qualitative data. Patients were recruited based on age, gender, ethnicity, and zip code. RESULTS A total of 104 patients were recruited: 34 young adults (19-39 years), 33 middle aged (40-64), and 37 senior citizens (>65). Young adults (mean 8.29, SD 1.66) reported higher computer self-efficacy than middle-aged participants (mean 5.56, SD 3.43; PP CONCLUSIONS Patients of different ages have different communication and technology preferences and different preferences with respect to how they would like information presented to them and how they wish to interact with their provider. The PHR is one approach to improving patient engagement, but nontechnological options need to be sustained to support all patients.

We examine authentication and security preferences of younger versus older patients in the healthcare domain. Previous research has investigated users' perception of the acceptability of various forms of authentication in non-healthcare domains, but not patients' preferences. First, we developed an interactive prototype to test three authentication methods: passwords, pattern, and voice. Our results indicate that younger patients prefer passwords by a significant margin. Older patients indicated more mixed preferences. In addition, we evaluated the level of security patients desired for protection of health information compared to financial information. We found no difference based on age: both groups felt financial security is more important than health data security. The findings of this research can be used to improve and enhance usability of future PHRs and overall PHR usage by patients. While this study is specific to cardiology patients we believe the results are generalizable to all patients with chronic conditions.

Electronic Health Records (EHRs) can improve the quality, safety, and efficiency of patient care. Migration to EHRs is progressing, but has been slowed by concerns related to interoperability, security, cost, patient safety, and usability. This paper focuses on EHR usability, specifically heuristic evaluation, or utilizing accepted guidelines for assessing EHR interface design. Health-care researchers initially applied industry-standard heuristics to EHRs, but subsequently health-care-specific groups have adapted and expanded these standard heuristics, calling for development and use of heuristics specific to EHRs. This paper first summarizes the evolution of heuristic evaluation of EHRs, then discusses the similarities and differences between these various approaches. This is an important step in developing community consensus on integrated heuristics, the basis of successful heuristic evaluation of EHRs. We then discuss the ‘Theory of Fit’ as a means of explaining the existence of these somewhat different heuristics, and close with suggestions for further research.

In 2004, President George W. Bush called for interoperable electronic health records (EHRs) for the majority of Americans within 10 years and established the Office of the National Coordinator for Health Information Technology (HIT), directed by Dr. David Brailer, whose Framework for Strategic

Richard J. Kovacs, MD, FACC, Chair Deepak Bhatt, MD, FACC Ralph Brindis, MD, MPH, MACC Paul N. Casale, MD, MPH, FACC Edward T.A. Fry, MD, FACC Paul A. Heidenreich, MD, FACC Jeffrey P. Jacobs, MD, FACC James L. Januzzi, Jr, MD, FACC Amy L. Miller, MD, PhD, FACC Athena Poppas, MD, FACC

Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1291 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1291 1. Purpose of This Document . . . . . . . . . . . . . . .1291 2. Document Development Process . . . . . . . . . .1291 3. Definitions, Terminology, and Regulations . . .1292 1. Terminology . . . . . . . . . . . . . . . . . . . .1292 2. Generics . . . . . . . . . . . . . . . . . . . . . . . .1293 3. Bioequivalence . . . . . . . . . . . . . . . . . .1293 4. Biologics and Biosimilars. . . . . . . . . . .1294 2. Pharmacogenomics . . . . . . . . . . . . . . . . . . . . . . . .1295 3. Federal Regulations and State Laws . . . . . . . . . . .1296 4. Therapeutic Approaches . . . . . . . . . . . . . . . . . . . . .1296 1. Therapeutic Interchange . . . . . . . . . . . . . . . . .1296 2. Therapeutic Substitution . . . . . . . . . . . . . . . . .1297 3. Generic Substitution . . . . . . . . . . . …

Objective. The purpose of this study was to determine the type of arrhythmias induced with therapeutic versus diagnostic transthoracic low-frequency ultrasound (TLFUS) transducers in the presence of intravenous microbubbles. Methods. Intravenous perfluorocarbon-exposed sonicated dextrose albumin (PESDA) microbubbles were infused or given as a bolus injection while TLFUS was applied in the standard parasternal and apical views with either a 1-MHz therapeutic ultrasound transducer or high-mechanical-index diagnostic ultrasound (1.7 MHz). Results. Significantly more ectopy was produced by the therapeutic transducer, especially at higher-intensity settings in the continuous wave mode after bolus injections of PESDA (P

Ultrafiltration (UF) is used to treat patients with diuretic-resistant acute decompensated heart failure. The aim of this study was to identify predictors and the effect of worsening renal failure (WRF) on mortality in patients treated with UF.Based on changes in serum creatinine, 99 patients treated with UF were divided into WRF and control groups. Overall creatinine increased from 1.9 ± 9.7 to 2.2 ± 2.0 mg/dL (P.001), and WRF developed in 41% of the subjects. The peak UF rate was higher in the WRF group in univariate analysis (174 ± 45 vs 144 ± 42 mL/h; P = .03). Based on multivariate analysis, aldosterone antagonist treatment (odds ratio [OR] 3.38, 95% confidence interval [CI] 1.17-13.46, P = .04), heart rate ≤65 beats/min (OR 6.03, 95% CI 1.48-48.42; P = .03), and E/E' ≥15 (OR 3.78, 95% CI 1.26-17.55; P = .04) at hospital admission were associated with WRF. Patients with baseline glomerular filtration rate (GFR) ≤60 mg/dL who developed WRF during UF had a 75% 1-year mortality rate.WRF occurred frequently during UF. Increased LV filling pressures, lower heart rate, and treatment with aldosterone antagonist at hospital admission can identify patients at increased risk for WRF. Patients with baseline GFR ≤60 mg/dL and WRF during UF have an extremely high 1-year mortality rate.

Table of Contents This document has been developed as a health policy statement (HPS) by the American College of Cardiology (ACC). HPSs are intended to promote or advocate a position, be informational in nature, and offer guidance to the stakeholder community regarding the stance of the ACC …

We have previously proposed the generalized eigensystem (GES) method as a modal expansion method for estimating electrical potentials on the heart outer surface from measurements of electrical potentials on the body surface. In this paper, we present an alternative formulation of GES more like that of classical Tikhonov regularization where a single continuous parameter needs to be chosen. We then compare this formulation of GES with zero order Tikhonov regularization on data collected from a swine experiment with the swine heart paced from six different sites. Of the two algorithms used to estimate the regularization parameters, the composite residual and smoothing operator (CRESO) generally outperforms the generalized cross validation (GCV) for both GES and Tikhonov. Although the inverse problems are solved at each time instant independently, we also incorporate temporal information by moving average filtering the estimates, and this is more effective for the GES methods than for Tikhonov. In general, t...

Cardiac transplantation has become the standard modality of treatment for selected patients with end-stage heart disease who are not candidates for alternative surgical procedure and who remain symptomatic in spite of maximal medical treatment. The majority of patients undergo cardiac transplantation because of refractory heart failure. Patients considered for cardiac transplantation typically have New York Heart Association (NYHA) functional Class IV congestive heart failure and an anticipated survival of less than 1 year without cardiac transplantation.1,2 While life-threatening ventricular arrhythmias are present in the majority of patients with end-stage cardiac disease and may contribute to their poor prognosis,3–5 arrhythmias are rarely the sole reason for transplantation. The exact number of patients who have undergone cardiac transplantation with the primary indication for the procedure being refractory ventricular arrhythmias is unknown. No data have been collected in this regard by either the Registry of the International Society for Heart and Lung Transplantation or by the United Network for Organ Sharing (UNOS). It has, however, been estimated by UNOS that less than 1% of the total cardiac transplants in adult recipients may have been performed because of refractory ventricular arrhythmias.6 In our own experience (over a 13-year period with almost 400 cardiac transplants) only three patients have been transplanted because of inability to control life-threatening arrhythmias in the absence of end-stage heart failure. According to the guidelines established at the Bethesda Conference on Cardiac Transplantation,1 which have been adopted by UNOS,6 patients with refractory ventricular arrhythmias and no symptoms of congestive heart failure should be considered for cardiac transplantation only in the event of either

In programming the implantable cardioverter defibrillator (ICD), the ventricular tachycardia (VT) detection cycle length (CL) is based on the CL of the documented tachycardia but the ventricular fibrillation (VF) detection CL is set arbitrarily. Appropriate programming of VF detection may not only reduce the incidence of inappropriate ICD shocks for non-VF rhythms but can also avoid the fatal underdetection of VF. The mean VFCL may provide a useful parameter for optimal ICD programming for VF detection if it is reproducible. This study examined the intrapatient reproducibility and interpatient variation of the mean VFCL in 30 ICD patients (25 men and 5 women, mean age 63 +/- 13 years). A total of 210 VF episodes (7 +/- 4 per patient, range 3-17) induced by T-wave shocks (166) or AC (44) at the ICD implant (30 patients) and the predischarge test (12 of 30 patients) were analyzed. The mean VFCL was calculated from the stored V-V intervals in the ICDs. Although the mean VFCL varied significantly from 171 +/- 6 to 263 +/- 11 ms (P0.01) among different patients, it was reproducible among different VF episodes in an individual patient (maximal variation 4-50 ms, P0.05). The mean VFCL was not significantly different between patients with and without antiarrhythmic drugs (210 +/- 32 vs 210 +/- 23 ms, P0.05) and was correlated with the ventricular effective refractory period (r = 0.5, P0.05). The mean VFCL varies greatly among different patients but remains reproducible in an individual patient, suggesting that the mean VFCL may serve as a reference for ICD programming of VF detection.

AF is the most common sustained cardiac arrhythmia. Recognition and appropriate management of AF is important to optimize care of concurrent medical problems and prevent long-term consequences. DC cardioversion under sedation should be performed in patients with pulmonary edema, angina, or hypotension. Ventricular rate control is the first choice in stable patients with rapid ventricular rate. Anticoagulation should be considered in all patients with AF duration48 hours, except for those under 65 years old and having no other risk factors of stroke. Recent data imply that early attempts at cardioversion may increase success rates and decrease AF recurrence rates. Thus, transesophageal echocardiogram-guided early cardioversion may become more widely used.

Summary Objective: The objective of this case report is to evaluate the importance of specialized domain knowledge when designing and using structured templated notes in a clinical environment. Methods: To analyze the impact of specialization on structured note generation we compared notes generated for three scenarios: 1) We compared the templated history of present illness (HPI) for patients presenting with a dermatology concern to the dermatologist versus the emergency department. 2) We compared the evaluation of chest pain by ED physicians versus cardiologists. 3) Finally, we compared the data elements asked for in the evaluation of the gastrointestinal system between cardiologists and the liver transplant service (LTS). We used the SNOMED CT representation via BioPortal to evaluate specificity and grouping between data elements and specialized physician groups. Results: We found few similarities in structured data elements designed by and for the specific physician groups. The distinctness represented both differences in granularity as well as fundamental differences in data elements requested. When compared to ED physicians, dermatologists had different and more granular elements while cardiologists requested much more granular data. Comparing cardiologists and LTS, there were differences in the data elements requested. Conclusion: This case study supports the importance of domain knowledge in EHR design and implementation. That different specialities should want and use different information is well supported by cognitive science literature. Despite this, it is rare for domain knowledge to be considered in EHR implementation. Physicians with correct domain knowledge should be involved in the design process of templated notes.

Pericardial constriction associated with the placement of intrapericardial defibrillator patches is a rare occurrence that is reported only one tenth as often in defibrillator patients as in patients undergoing other types of cardiac operations. Although this discrepancy may be attributable to a lower incidence of constriction with the defibrillator patch electrode procedure, it may also indicate a failure to recognize that progressive right heart failure and signs of low cardiac output that could be due to pericardial constriction and not progressive systolic dysfunction. Because surgical removal of the patches and decortication of the epicardial surface is the only effective therapy, it is important to recognize this uncommon, but profoundly debilitating entity.

Coronary artery disease is the underlying etiology of left ventricular dysfunction and arrhythmias in most patients who receive implantable cardioverter defibrillators (ICDs). The aim of this study was to assess the safety and feasibility of dobutamine stress echocardiography (DSE) in patients with an ICD. DSE (dobutamine up to 50 μg/kg/min, atropine up to 2 mg) was performed in 87 patients with an ICD and known or suspected coronary artery disease. The ICD was inactivated before the stress test and reactivated after the study; no serious complications occured. DSE is a safe and feasible method for evaluating myocardial ischemia in patients with an ICD.

With the increasing flexibility allowed by implantable cardioverter defibrillators that use tiered therapy, it is important to match the therapy with the arrhythmia. In this article we present scatter diagram analysis, a new computationally efficient two-channel algorithm for distinguishing monomorphic ventricular tachycardia (VT) from polymorphic ventricular tachycardia and ventricular fibrillation (VF). Scatter diagram analysis plots the amplitude from one channel versus the amplitude from another channel on a graph with a 15 x 15 grid. The fraction (percentage) of the 225 grid blocks occupied by at least one sample point is then determined. We found that monomorphic VT traces nearly the same path in space and occupies a smaller percentage of the graph than a nonregular rhythm such as polymorphic VT or VF. Scatter diagram analysis was tested on 27 patients undergoing intraoperative implantable cardioverter defibrillator testing. Passages of 4.096 seconds were obtained from rate (bipolar epicardial) and morphology (patch) leads, and digitized at 125 Hz. Scatter diagram analysis distinguished 13 episodes of monomorphic VT (28.6% +/- 4.0%) from 27 episodes of polymorphic VT or VF (48.0% +/- 8.2%) with P < 0.0005. There was overlap in only one monomorphic VT episode and one polymorphic VT or VF episode.

SummaryObjective: The slow adoption of electronic health record (EHR) systems has been linked to physician resistance to change and the expense of EHR adoption. This qualitative study was conducted to evaluate benefits, and clarify limitations of two mature, robust, comprehensive EHR Systems by tech-savvy physicians where resistance and expense are not at issue.Methods: Two EHR systems were examined – the paperless VistA / Computerized Patient Record System used at the Veterans‘ Administration, and the General Electric Centricity Enterprise system used at an academic medical center. A series of interviews was conducted with 20 EHR-savvy multi-institutional internal medicine (IM) faculty and house staff. Grounded theory was used to analyze the transcribed data and build themes. The relevance and importance of themes were constructed by examining their frequency, convergence, and intensity.Results: Despite eliminating resistance to both adoption and technology as drivers of acceptance, these two robust EHR’s are still viewed as having an adverse impact on two aspects of patient care, physician workflow and team communication. Both EHR’s had perceived strengths but also significant limitations and neither were able to satisfactorily address all of the physicians’ needs.Conclusion: Difficulties related to physician acceptance reflect real concerns about EHR impact on patient care. Physicians are optimistic about the future benefits of EHR systems, but are frustrated with the non-intuitive interfaces and cumbersome data searches of existing EHRs.

SummaryObjective: Less than 20% of hospitals in the US have an electronic health record (EHR). In this qualitative study, we examine the perspectives of both academic and private physicians and administrators as stakeholders, and their alignment, to explore their perspectives on the use of technology in the clinical environment.Methods: Focus groups were conducted with 74 participants who were asked a series of open-ended questions. Grounded theory was used to analyze the transcribed data and build convergent themes. The relevance and importance of themes was constructed by examining frequency, convergence, and intensity. A model was proposed that represents the interactions between themes. Results: Six major themes emerged, which include the impact of EHR systems on workflow, patient care, communication, research/outcomes/billing, education/learning, and institutional culture. Academic and private physicians were confident of the future benefits of EHR systems, yet cautious about the current implementations of EHR, and its impact on interactions with other members of the healthcare team and with patients, and the amount of time necessary to use EHR’s. Private physicians differed on education and were uneasy about the steep learning curve necessary for use of new systems. In contrast to physicians, university and hospital administrators are optimistic, and value the availability of data for use in reporting.Conclusion: The results of our study indicate that both private and academic physicians concur on the need for features that maintain and enhance the relationship with the patient and the healthcare team. Resistance to adoption is related to insufficient functionality and its potential negative impact on patient care. Integration of data collection into clinical workflows must consider the unexpected costs of data acquisition.

Vasovagal syncope is the most common cause of syncope, but its risk for driving remains uncertain. We analyzed the clinical characteristics of patients who had syncope during driving and subsequently underwent the head-up tilt test (HUTT). Of the 245 consecutive patients undergoing HUTT, 23 (9%) hador =1 episode of syncope during driving. HUTT was positive in 19 (group A) and negative in 4 (group B) patients. No patient had structural heart disease. In group A, the driving incident occurred on the first syncope in 3 patients, and the other 16 patients had 1 to 4 episodes of prior syncope not associated with driving. In group B, the driving incident occurred on the first syncope in 1 patient, and the other 3 patients had prior syncope (3 episodes in each) not associated with driving. Seven group A and 1 group B patients had 2 syncope-related driving incidents, and the remaining patients had only 1 syncope-related driving incident. The syncope-related driving incidents caused personal injury in 7 group A and 2 group B patients. One incident in 1 group A patient caused the death of another driver. After HUTT, all but 1 patient in group A received medical treatment and only 1 patient in group B received empirical beta-blocker therapy. During the follow-up of 51+/-26 months, 1 patient died and another was lost to follow-up. Of the remaining patients, 4 patients had recurrence of syncope and 2 patients had presyncope in group A. One of these patients had another syncope-related driving incident. No group B patient had syncope recurrence. A second etiology of syncope was never found in any patient. We conclude that vasovagal syncope during driving is not uncommon in patients referred for syncope evaluation. Early medical attention to patients with vasovagal syncope may help reduce syncope-related driving incidents.

We compared signal-averaged electrocardiography with invasive electrophysiological study in patients after surgical repair of congenital heart disease to determine if potentially useful correlations exist between the two methods for assessment of risk for ventricular tachycardia. Thirty-one patients (age, 1-49 years; mean, 10.6 years) with congenital heart disease repaired with right ventriculotomy or postrepair right bundle branch block (77% postoperative tetralogy of Fallot) who had electrophysiological study were studied with signal-averaged electrocardiography. Patients were classified by electrophysiological study results as having no inducible ventricular tachycardia, nonsustained ventricular tachycardia, or sustained ventricular tachycardia. Signal-averaged electrocardiograms were examined for the duration of low-amplitude (less than or equal to 40 microV) QRS signal, duration of total QRS, and root-mean-square voltage of the terminal 40 msec of the QRS. Low-amplitude terminal root-mean-square voltage of 100 microV or less had 91% sensitivity and 70% specificity for ventricular tachycardia inducible by electrophysiological study. Similar sensitivity but less specificity were seen using the criterion of 20 msec or more total low-amplitude QRS signal (initial plus terminal) or using total QRS duration of 128 msec or more. There was a weaker association between terminal low-amplitude QRS signal of 15 msec or more and inducible ventricular tachycardia.(ABSTRACT TRUNCATED AT 250 WORDS)