Journal of the American Medical Informatics Association最新文献

Objectives: Visual hierarchy underlies all visual design decisions related to information presentation. This manuscript describes the experience of a multidisciplinary health data visualization and software design team in using visual hierarchy to redesign a hereditary colorectal cancer lab report.

Materials and methods: A series of interviews with representative users were conducted to identify target user groups and determine information hierarchy for each user type. Visual elements (eg, size, color, contrast, etc.) were then assigned to mirror the information hierarchy and workflow for each user type.

Results: User research identified 2 distinct user groups as consumers of the redesigned lab report. An interactive design employing a 2-level page hierarchy was developed, which stratified the content to support the needs of each user type.

Conclusions: The challenges related to displaying the complex nature of digital and personal health data can be addressed by applying foundational design methods such as visual hierarchy.

Discussion: Visual hierarchy, a foundational design principle, can be used by visualization teams to clearly and efficiently present complex datasets associated with healthcare.

The integration of large language models (LLMs) like ChatGPT into medical education presents potential benefits and challenges. These technologies, aligned with constructivist learning theories, could potentially enhance critical thinking and problem-solving through inquiry-based learning environments. However, the actual impact on educational outcomes and the effectiveness of these tools in fostering learning require further empirical study. This technological shift necessitates a reevaluation of curriculum design and the development of new assessment methodologies to measure its effects accurately. Additionally, the use of LLMs introduces significant ethical concerns, particularly in addressing inherent AI biases to ensure equitable educational access. LLMs may also help reduce global disparities in medical education by providing broader access to contemporary medical knowledge and practices, though their deployment must be managed carefully to truly support the training of competent, ethical medical professionals.

Importance and objective: Identifying sources of sex-based disparities is the first step in improving clinical outcomes for female patients. Using All of Us data, we examined the association of biological sex with cost-related medication adherence (CRMA) issues in patients with cardiovascular comorbidities.

Materials and methods: Retrospective data collection identified the following patients: 18 and older, completing personal medical history surveys, having hypertension (HTN), ischemic heart disease (IHD), or heart failure (HF) with medication use history consistent with these diagnoses. Implementing univariable and adjusted logistic regression, we assessed the influence of biological sex on 7 different patient-reported CRMA outcomes within HTN, IHD, and HF patients.

Results: Our study created cohorts of HTN (n = 3891), IHD (n = 5373), and HF (n = 2151) patients having CRMA outcomes data. Within each cohort, females were significantly more likely to report various cost-related medication issues: being unable to afford medications (HTN hazards ratio [HR]: 1.68, confidence interval [CI]: 1.33-2.13; IHD HR: 2.33, CI: 1.72-3.16; HF HR: 1.82, CI: 1.22-2.71), skipping doses (HTN HR: 1.76, CI: 1.30-2.39; IHD HR: 2.37, CI: 1.69-3.64; HF HR: 3.15, CI: 1.87-5.31), taking less medication (HTN HR: 1.86, CI: 1.37-2.45; IHD HR: 2.22, CI: 1.53-3.22; HF HR: 2.99, CI: 1.78-5.02), delaying filling prescriptions (HTN HR: 1.83, CI: 1.43-2.39; IHD HR: 2.02, CI: 1.48-2.77; HF HR: 2.99, CI: 1.79-5.03), and asking for lower cost medications (HTN HR: 1.41, CI: 1.16-1.72; IHD HR: 1.75, CI: 1.37-2.22; HF HR: 1.61, CI: 1.14-2.27).

Discussion and conclusion: Our results clearly demonstrate CRMA issues disproportionately affect female patients with cardiovascular comorbidities, which may contribute to the larger sex-based disparities in cardiovascular care. These findings call for targeted interventions and strategies to address these disparities and ensure equitable access to cardiovascular medications and care for all patients.

Objectives: We evaluated the effectiveness and implementability of a standardized EHR-integrated handoff report to support intraoperative handoffs.

Materials and methods: A pre-post intervention study was used to compare the quality of intraoperative handoffs supported by unstructured notes (pre) to structured, standardized EHR-integrated handoff reports (post). Participants included anesthesia clinicians involved in intraoperative handoffs. A mixed-method approach was followed, supported by general observations, shadowing, surveys, and interviews.

Results: One hundred and fifty-one intraoperative permanent handoffs (78 pre, 73 post) were included. One hundred percent of participants in the post-intervention cohort utilized the report. Compared to unstructured, structured handoffs using the EHR-integrated handoff report led to: (1) significant increase in the transfer of information about airway management (55%-78%, P < .001), intraoperative course (63%-86%, P < .001), and potential concerns (64%-88%, P < .001); (2) significant improvement in clinician satisfaction scores, with regards to information clarity and succinctness (4.5-4.7, P = .002), information transfer (3.8-4.2, P = .011), and opportunities for fewer errors reported by senders (3.3-2.5, P < .001) and receivers (3.2-2.4, P < .001); and (3) significant decrease in handoff duration (326.2-262.3 s, P = .016). Clinicians found the report implementation highly acceptable, appropriate, and feasible but noted a few areas for improvement to enhance its usability and integration within the intraoperative workflow.

Discussion and conclusion: A standardized EHR-integrated handoff report ensures the effectiveness and efficiency of intraoperative handoffs with its structured, consistent format that-promotes up-to-date and pertinent intraoperative information transfer; reduces opportunities for errors; and streamlines verbal communication. Handoff standardization can promote safe and high-quality intraoperative care.

Objectives: Active learning (AL) has rarely integrated diversity-based and uncertainty-based strategies into a dynamic sampling framework for clinical named entity recognition (NER). Machine-assisted annotation is becoming popular for creating gold-standard labels. This study investigated the effectiveness of dynamic AL strategies under simulated machine-assisted annotation scenarios for clinical NER.

Materials and methods: We proposed 3 new AL strategies: a diversity-based strategy (CLUSTER) based on Sentence-BERT and 2 dynamic strategies (CLC and CNBSE) capable of switching from diversity-based to uncertainty-based strategies. Using BioClinicalBERT as the foundational NER model, we conducted simulation experiments on 3 medication-related clinical NER datasets independently: i2b2 2009, n2c2 2018 (Track 2), and MADE 1.0. We compared the proposed strategies with uncertainty-based (LC and NBSE) and passive-learning (RANDOM) strategies. Performance was primarily measured by the number of edits made by the annotators to achieve a desired target effectiveness evaluated on independent test sets.

Results: When aiming for 98% overall target effectiveness, on average, CLUSTER required the fewest edits. When aiming for 99% overall target effectiveness, CNBSE required 20.4% fewer edits than NBSE did. CLUSTER and RANDOM could not achieve such a high target under the pool-based simulation experiment. For high-difficulty entities, CNBSE required 22.5% fewer edits than NBSE to achieve 99% target effectiveness, whereas neither CLUSTER nor RANDOM achieved 93% target effectiveness.

Discussion and conclusion: When the target effectiveness was set high, the proposed dynamic strategy CNBSE exhibited both strong learning capabilities and low annotation costs in machine-assisted annotation. CLUSTER required the fewest edits when the target effectiveness was set low.

Objective: Conduct a scoping review of research studies that describe rule-based clinical decision support (CDS) malfunctions.

Materials and methods: In April 2022, we searched three bibliographic databases (MEDLINE, CINAHL, and Embase) for literature referencing CDS malfunctions. We coded the identified malfunctions according to an existing CDS malfunction taxonomy and added new categories for factors not already captured. We also extracted and summarized information related to the CDS system, such as architecture, data source, and data format.

Results: Twenty-eight articles met inclusion criteria, capturing 130 malfunctions. Architectures used included stand-alone systems (eg, web-based calculator), integrated systems (eg, best practices alerts), and service-oriented architectures (eg, distributed systems like SMART or CDS Hooks). No standards-based CDS malfunctions were identified. The "Cause" category of the original taxonomy includes three new types (organizational policy, hardware error, and data source) and two existing causes were expanded to include additional layers. Only 29 malfunctions (22%) described the potential impact of the malfunction on patient care.

Discussion: While a substantial amount of research on CDS exists, our review indicates there is a limited focus on CDS malfunctions, with even less attention on malfunctions associated with modern delivery architectures such as SMART and CDS Hooks.

Conclusion: CDS malfunctions can and do occur across several different care delivery architectures. To account for advances in health information technology, existing taxonomies of CDS malfunctions must be continually updated. This will be especially important for service-oriented architectures, which connect several disparate systems, and are increasing in use.

Objectives: To understand how frailty and healthcare delays differentially mediate the association between sexual and gender minority older adults (OSGM) status and healthcare utilization.

Materials and methods: Data from the All of Us Research Program participants ≥50 years old were analyzed using marginal structural modelling to assess if frailty or healthcare delays mediated OSGM status and healthcare utilization. OSGM status, healthcare delays, and frailty were assessed using survey data. Electronic health record (EHR) data was used to measure the number of medical visits or mental health (MH) visit days, following 12 months from the calculated All of Us Frailty Index. Analyses adjusted for age, race and ethnicity, income, HIV, marital status ± general MH (only MH analyses).

Results: Compared to non-OSGM, OSGM adults have higher rates of medical visits (adjusted rate ratio [aRR]: 1.14; 95% CI: 1.03, 1.24) and MH visits (aRR: 1.85; 95% CI: 1.07, 2.91). Frailty mediated the association between OSGM status medical visits (Controlled direct effect [Rcde] aRR: 1.03, 95% CI [0.87, 1.22]), but not MH visits (Rcde aRR: 0.37 [95% CI: 0.06, 1.47]). Delays mediated the association between OSGM status and MH visit days (Rcde aRR: 2.27, 95% CI [1.15, 3.76]), but not medical visits (Rcde aRR: 1.06 [95% CI: 0.97, 1.17]).

Discussion: Frailty represents a need for medical care among OSGM adults, highlighting the importance of addressing it to improve health and healthcare utilization disparities. In contrast, healthcare delays are a barrier to MH care, underscoring the necessity of targeted strategies to ensure timely MH care for OSGM adults.

Objectives: Patients with chronic illnesses, including kidney disease, consider their sense of normalcy when evaluating their health. Although this concept is a key indicator of their self-determined well-being, they struggle to understand if their experience is typical. To address this challenge, we set out to explore how to design personal health visualizations that aid participants in better understanding their experiences post-transplant, identifying barriers to normalcy, and achieving their desired medical outcomes.

Materials and methods: Pediatric kidney transplant patients and their caregivers participated in three asynchronous design sessions involving sharing experiences, presenting symbolic objects, and providing feedback on visualizations to understand their perceptions of normalcy post-transplant. Data analysis of design session 1 and 2 comprised deductive and inductive analysis. We used affinity diagramming to identify thematic areas about participants' transplant experiences. Comprehension of design session three normalcy visualizations was also evaluated.

Results: Participants effectively engaged in the design sessions, revealing diverse perspectives on their experiences. We found there is a significant need for visualizations that depict normalcy to better inform patients and caregivers about their health.

Discussion: Normalcy Visualizations should incorporate three key design principles: personal values, facilitating peer and self-comparison, and seamlessly communicating abstract concepts to help youth kidney transplant recipients comprehend and contextualize if their transplant experience is normal and what normalcy means to them.

Conclusion: By incorporating holistic aspects of patients' and caregivers' lives into personal health visualizations, they can be cognizant of their progress to normalcy and empowered to make decisions that help them feel normal.

Objective: The All of Us Research Program aims to return value to participants by developing research capacity in communities. We describe a novel set of introductory exercises (Data Sandboxes) and specialized trainings to orient researchers to the Researcher Workbench to foster health equity research.

Materials and methods: We developed a tailored training to familiarize researchers with the All of Us Research Program: (1) orientation, (2) tailored "data treasure hunt" using the Public Data Browser, and (3) overview of the analyses tools and platform.

Results: Participants' pre- and post-knowledge of the contents and structure of the All of Us dataset scores increased significantly after training. These trainings effectively engaged researchers in exploring this rich dataset.

Conclusion: We describe ways of orienting and familiarizing a wide variety of researchers with the All of Us Research Program dataset, sparking their interest, and "jump-starting" their research.

Objective: We aimed to evaluate the feasibility of using ChatGPT as programming support for nursing PhD students conducting analyses using the All of Us Researcher Workbench.

Materials and methods: 9 students in a PhD-level nursing course were prospectively randomized into 2 groups who used ChatGPT for programming support on alternating assignments in the workbench. Students reported completion time, confidence, and qualitative reflections on barriers, resources used, and the learning process.

Results: The median completion time was shorter for novices and certain assignments using ChatGPT. In qualitative reflections, students reported ChatGPT helped generate and troubleshoot code and facilitated learning but was occasionally inaccurate.

Discussion: ChatGPT provided cognitive scaffolding that enabled students to move toward complex programming tasks using the All of Us Researcher Workbench but should be used in combination with other resources.

Conclusion: Our findings support the feasibility of using ChatGPT to help PhD nursing students use the All of Us Researcher Workbench to pursue novel research directions.