Publications

PURPOSE

EyePACS is an application for communicating and archiving eye-related patient information, images, and diagnostic data. We studied how users adopted the system in diverse clinical settings.

METHODS

53 clinicians and 142 students uploaded cases over 2.5 years from 6 pilot sites: a university teaching clinic, a university glaucoma clinic, an urban private optometric practice, a rural elderly care facility, a diabetic management program, and an eye hospital in India.

RESULTS

EyePACS collected 1,122 cases. Users employed it for informal "curbside" consults in 17% of cases. Other uses of the system were: 1) to replace telephone and fax referrals to a retinal specialist (10%), 2) as part of ocular teleconsultations and diabetic retinopathy screening (31%), 3) for education via digital grand rounds and evaluation of students (32%), and 4) for research (10%).

CONCLUSION

EyePACS has been used successfully for consults and education in diverse settings. The resulting database of digital cases serves as a searchable reference for clinicians.

BACKGROUND

There is growing recognition that physician use of electronic medical records (EMRs) is critical for improving quality of care in outpatient settings.

METHODS

We inter-viewed EMR physician champions from 20 solo/small group practices to understand different types of EMR users and their EMR-related costs and benefits.

RESULTS

Interviewees differed greatly in the EMR-related benefits they generated. These differences were associated with how they used the EMR, and the amount of effort they invested in making changes to complement EMR use. We defined five types of physician EMR users: Viewers, Basic Users, Strivers, Arrivers, and System Changers. The majority of interviewees were Strivers and Arrivers, physicians who have already invested substantial time in numerous process changes that help generate EMR-related benefits.

CONCLUSIONS

Incentives and comprehensive support services for facilitating complementary process changes could be important for moving physicians from one user group to another. Additional research is needed to verify this user typology and to further define the relationship between user types and EMR-generated financial and quality benefits.

Computer-based clinical decision support systems (CDSSs) have been championed for their potential to improve health-care quality. However, there has been no systematic study of the types of CDSSs that have been developed. In previous work, we developed the CDSS Taxonomy for comprehensively describing the technical, workflow, and contextual characteristics of CDSSs. We now use the CDSS Taxonomy to describe outpatient CDSSs evaluated in randomized controlled trials published between 1998 and 2002. 31 studies comprising 42 CDSS systems were included in our analysis. The majority of systems used rule-based reasoning engines to "push" explicit, individualized recommendations concerning non-urgent decisions to clinicians or patients, but not both. 71% of the systems required someone to manually enter data into the system or to process the system output for use by the target decision maker. The average kappa for coding agreement was > 0.6. Our findings demonstrate that outpatient CDSSs vary greatly in design and function. Many impose a data entry or output-processing burden on clinic staff. More complete reporting of CDSS characteristics is needed in the literature.

The Society of General Internal Medicine asked a task force to redefine the domain of general internal medicine. The task force believes that the chaos and dysfunction that characterize today's medical care, and the challenges facing general internal medicine, should spur innovation. These are our recommendations: while remaining true to its core values and competencies, general internal medicine should stay both broad and deep-ranging from uncomplicated primary care to continuous care of patients with multiple, complex, chronic diseases. Postgraduate and continuing education should develop mastery. Wherever they practice, general internists should be able to lead teams and be responsible for the care their teams give, embrace changes in information systems, and aim to provide most of the care their patients require. Current financing of physician services, especially fee-for-service, must be changed to recognize the value of services performed outside the traditional face-to-face visit and give practitioners incentives to improve quality and efficiency, and provide comprehensive, ongoing care. General internal medicine residency training should be reformed to provide both broad and deep medical knowledge, as well as mastery of informatics, management, and team leadership. General internal medicine residents should have options to tailor their final 1 to 2 years to fit their practice goals, often earning a certificate of added qualification (CAQ) in special generalist fields. Research will expand to include practice and operations management, developing more effective shared decision making and transparent medical records, and promoting the close personal connection that both doctors and patients want. We believe these changes constitute a paradigm shift that can benefit patients and the public and reenergize general internal medicine.

This paper describes and compares 2 random-digit dialing (RDD) methods that have been used to select minority subjects for population-based research. These methods encompass the census-based method, which draws its primary sampling units from census tracts with a high proportion of minority persons, and the registry-based method, which derives its primary sampling units from a population-based cancer registry. Our study targeted Filipinos living in 10 Northern California counties, where they constitute 4% of the total population. Eligible participants (Filipina women, at least aged 20, who spoke 1 of 4 interview languages) were asked to complete a short telephone interview. Both the census and registry methods located Filipino households with comparable efficiency and with a higher yield than would be expected in a non-targeted population survey, such as the Mitofsky-Waksberg RDD method. No systematic pattern of responses was evident that would indicate that either method sampled women who were systematically less acculturated or less likely to use cancer screening tests. Although both methods offer substantial gains in efficiency, their utility is limited by generating samples that tend to over-represent high-density areas. The degree to which these methods are considered viable depends on further refinement to limit, or eliminate, their inherent selection biases without sacrificing their increased efficiency to locate minority populations.

Experimental evidence demonstrates that inflammation plays a key role in the pathogenesis of an atherosclerotic plaque. Whereas multiple, large, prospective epidemiologic studies demonstrate that C-reactive protein (CRP) and other inflammatory biomarkers predict future risk of cardiovascular disease (CVD), data on inflammation among specific ethnic groups in the United States are sparse. For example, CRP levels may vary by race/ethnicity but more data are needed to better assess this issue. Additionally, data on the relationship between white blood cell (WBC) count and CVD among African American and Hispanic participants suggest that elevated WBC is associated with increased likelihood of vascular disease. Furthermore, some research suggests that African Americans may have different fibrinolytic characteristics than white Americans. Generally, fibrinogen levels have been noted to be higher among African Americans than among white Americans. Although data regarding inflammatory biomarkers of CVD in various ethnic groups are slowly emerging, the lack of adequate representation of African Americans in clinical cohorts continues to be the limiting factor in data ascertainment.

Despite advances in cardiac arrhythmia management, atrial fibrillation remains a major cause of cardiovascular morbidity and mortality. Recent data suggests that there are periods of organization within this apparently chaotic arrhythmia. To date, analysis of the rapidly changing atrial fibrillation signal has been limited by a lack of time-frequency resolution. When used to analyze high-density atrial mappings of this arrhythmia, the continuous wavelet transform, with its time-frequency multi-resolution capability, may provide important temporal and spatial information regarding arrhythmia organization and may lead to the development of more effective therapies.

While the proximal cytoplasmic signalling events controlling the activation of NF-kappaB are understood in considerable detail, the subsequent intranuclear events that regulate the strength and duration of NF-kappaB action remain poorly defined. Recently, we have demonstrated that the RelA subunit of the NF-kappaB heterodimer is subject to reversible acetylation. The p300/CBP acetyltransferases play a major role in the in vivo acetylation of RelA principally targeting lysines 218, 221 and 310 for modification. Acetylation of these distinct lysine residues regulates different functions of NF-kappaB, including transcriptional activation, DNA binding affinity, I-kappaBalpha assembly and subcellular localization. Specifically, acetylation of lysine 221 enhances DNA binding and impairs assembly with I-kappaBalpha while acetylation of lysine 310 is required for full transcriptional activity of RelA independent of changes in DNA binding or I-kappaBalpha binding. In turn, acetylated RelA is deacetylated by histone deacetylase 3 (HDAC3). Deacetylation of lysine 221 promotes high-affinity binding of RelA to newly synthesized I-kappaBalpha proteins whose expression is activated by NF-kappaB. I-kappaBalpha binding to deacetylated RelA promotes rapid nuclear export of the NF-kappaB complex. This export is dependent on CRM1 binding to a nuclear export signal present in I-KBalpha and promotes replenishment of the cytoplasmic pool of latent NF-kappaB/I-kappaBalpha complexes thus readying the cell for response to the next NF-kappaB inducing stimulus Together, these studies highlight how reversible acetylation of RelA serves as an intranuclear molecular switch promoting both positive and negative regulatory effects on nuclear NF-kappaB action.