Digital divide for electronic health records worth investigating, researcher says

Posted November 15, 2017 by Jennifer Huber
Categories: Health

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Photo by mcmurryjulie

Over the past several years, most hospitals have adopted electronic health records — a digital version of a patient’s medical chart that can contain information from all clinicians involved in a patient’s care. The goal is to provide better, more coordinated care through EHRs, although they are also increasingly cited as a source of physician burnout.

But there may be another problem with the implementation of EHR systems: although EHR adoption is widespread, the use of the records varies at different hospitals. According to a recent presentation at the 2017 American Medical Informatics Association’s annual meeting, hospitals with fewer resources are less likely to use the advanced functionality of EHRs for measuring performance and engaging patients.

The University of Michigan researchers analyzed data from almost 3000 medical-surgical acute care hospitals in the United States, based on the 2008 to 2015 American Hospital Association Annual and IT Supplement surveys.

First, they evaluated which hospitals have adopted “basic” verses “comprehensive” EHR functions. They found larger, urban hospitals participating in payment reforms were far more likely to use a comprehensive system than small, rural and safety-net hospitals — creating a digital “use” divide of EHRs.

Next, the researchers analyzed questions newly available on the 2015 Supplement to further assess hospital use of EHRs for 10 performance measurement and patient engagement functions. Over all hospitals, the most commonly adopted performance measurement functions were used to monitor patient safety and create dashboards of individual provider performance. Similarly, the most common patient engagement function allowed patients to view data online and download it.

However, critical access hospitals overall were less likely to have adopted eight or more of the ten EHR functions of either category.

The conference speaker Julie Adler-Milstein, PhD, was an associate professor at the University of Michigan during this research and is now at the University of California, San Francisco Medical Center. She said she is concerned about this emerging divide because these advanced EHR functions are essential for improving hospital performance. “We do need to consider what we can be doing to help safety-net hospitals make sure that they are able to continue their adoption trajectory and invest in some of these more substantive and important capabilities,” said Adler-Milstein in a recent news piece.

Specifically, the authors recommended in the abstract that policymakers drive greater EHR adoption using direct funding for health IT and indirect incentives to promote value-based payment and delivery models. They concluded, “Policymakers may need to consider specific actions to target safety-net hospitals, which could include funding as well as technical assistance with implementation.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

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Researchers investigate new treatment for glaucoma

Posted November 13, 2017 by Jennifer Huber
Categories: Health

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As an avid reader, I find I can get through just about anything if I can decompress and escape into a good book — so the idea of losing my vision is scary. However, millions of Americans face this fear due to glaucoma, a leading cause of blindness for those over 60.

Now, vision scientists at the University of California, Berkeley have discovered a new target for treating glaucoma, as recently reported in the Journal of Clinical Investigation.

Glaucoma is a neurodegenerative disease of the major nerve of vision, called the optic nerve. Typically, fluid builds up in the front part of the eye, causing pressure that irreversibly damages the optic nerve. If left untreated, glaucoma can lead to vision loss and permanent blindness.

Current treatments focus on lowering eye pressure using eye drops, oral medications, laser therapy or surgery. But researchers are searching for a way to prevent or stop the neurodegeneration itself. Berkeley researchers have now identified a new mechanism for stopping this degeneration in rats and mice with glaucoma.

Their research focused on the role of retinal astrocytes — cells that help make up the nerve fiber layer of the retina and optic nerve — which are important for developing and maintaining healthy eyes. They discovered that retinal astrocytes release powerful molecules called lipoxins A4 and B4 that act locally to dampen inflammation and help coordinate protective signaling for neurons in the eye. Surprisingly, they determined that astrocytes produce less of these lipoxins in eyes affected by glaucoma.

“Our research discovered that astrocytes that are triggered by injury actually turn off novel neuroprotective signals that prevent optic nerve damage,” explained study senior author John Flanagan, OD, PhD, professor and dean of optometry at UC Berkeley, in a recent news release.

The research team then tested the most promising lipoxin B4 as a therapy. Rodents were treated with lipoxin B4 eight weeks after developing glaucoma-like effects — the critical time point when the neurodegeneration typically becomes irreversible. After 15 weeks, they found that lipoxin B4 stopped the cells’ neurodegeneration.

Based on these encouraging results, the Berkeley researchers plan to further explore the therapeutic potential of these lipoxins for glaucoma and other neurodegenerative diseases, such as Alzheimer’s and Parkinson’s.

“These naturally occurring small lipids have great potential as therapies because they may play a fundamental role in preventing other neurodegenerative diseases. And that’s hugely significant,” said Flanagan in the release.

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Educating the next generation of surgeons: A Q&A

Posted November 9, 2017 by Jennifer Huber
Categories: Health, Science Education

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Photo by Rachel Baker

Research shows that many medical students view surgeons as intimidating, competitive and predominantly male workaholics — and these stereotypes can deter students from a surgical career. As a result, there has been a relative drop in applications for surgical residencies.

James Lau, MD, a clinical professor of surgery and the director of the Goodman Surgical Educational Center at Stanford, is working to combat this trend by spearheading educational initiatives. I caught up with him recently.

Why is there a declining interest in surgical careers?

“Medical students are becoming more sophisticated in choosing specialties, and a lot likely has to do with life style issues. I think there’s a misconception that surgeons work all the time and can’t have a work-life balance.

Medical schools are also getting shorter — some are even going to three years and some schools are emphasizing primary care — so students aren’t exposed early on to surgery. So we’ve built a mentorship component into our SURG 205 surgical training course to give first- and second-year medical students at Stanford the opportunity to go into the operating room and learn what surgery is like. And it sparks the flame and shows them more accurately the collegiality and dedication of those in surgery.”

What do your students learn in SURG 205?

“Previously the students would have to find a mentor and negotiate the system on their own to get the training to be allowed in the operating room. This course brings it all together —training them on technical skills, facilitating finding them a mentor, experiencing one or two operations and hopefully building an ongoing mentor relationship with an attending surgeon.

We want them to participate in the OR, so we train them on technical skills — from the simple skills like knot-tying and basic suturing to performing a full case on a cadaver. As we explained in a recent paper, we also teach them nontechnical skills, such as coaching them on how to get along with the operating team, so they feel more comfortable when they go to the OR.”

What other educational efforts are underway?

“Surgery residents and surgeons have to know more than technical skills to do operations. They also have to work well together in teams in different settings. They have to be able to interact well with patients and make clinical decisions. And the techniques are changing all the time. So we provide a skills and simulation center with a curriculum — to help teach and mentor these skills.

We also must train inter-professionally in surgery. The nurses, anesthesiologists and surgeons all work together but traditionally train separately, which makes no sense. In a new program, we’re having monthly simulations in the operating room with surgeons, surgery residents, anesthesiologists, anesthesiology residents, OR assistants, scrub technicians, circulating nurses, and anyone else that would normally be in the operating room. We want people to understand that everyone has a role and should speak up in crisis. We’re trying to change the culture by training together.

We also have a resident as educator program, because our residents are automatically teachers and mentors to the medical students. To be a good teacher, you have to be a constant learner and create a safe learning environment. A good teacher is a good communicator and their learners include the patients.”

Why did you recently get a Master’s Degree in Health Professions Education?

“I oversee a two-year surgical education fellowship that has surgery residents teach, create curricula and evaluate the work that they do in the clerkships and residency education programs here at Stanford. Our goal is to prepare them to be thoughtful program directors, helping to make them the next generation’s education leaders in surgery. As part of the program, we encourage them to complete a master’s degree in education. To be a mentor for them, I decided to ‘walk the walk’ and get a masters degree in education. After a decade in education, I wanted to inform myself in the formal discipline of education to become more effective in the programs that we create for learners here at Stanford.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Stanford researchers grow neural stem cells more efficiently in 3-D gel

Posted November 7, 2017 by Jennifer Huber
Categories: biology, Health

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Photo by luismmolina/Getty Images

Stem cells have the potential to help us understand and treat a range of diseases and injuries — from vision loss to cancers. For instance, a Japanese man in his 60s was recently treated for vision loss due to macular degeneration using stem cells donated by another person. And many other clinical trials involving stem cells are underway.

However, there is still a lot to learn about stem cells and many barriers to overcome before most potential treatments can be realized. One such barrier is how to grow large quantities of stem cells while maintaining their unique properties. Now, Stanford researchers have developed a new gel in which they can grow massive numbers of neural stem cells in less space.

Stem cells are unspecialized cells that can self-renew and develop into many different types of cells in the body. Researchers hope that neural stem cells — that differentiate into neurons and glia cells in the nervous system — can be used to treat spinal cord injuries, Parkinson disease, Huntington disease and other nervous system disorders.

As recently reported in Nature Materials, the Stanford team engineered a new polymer-based gel optimized for neural stem cells, growing them in three dimensions instead of two.

“For a 3-D culture, we need only a 4-inch-by-4-inch plot of lab space, or about 16 square inches. A 2-D culture requires a plot of four feet by four feet, or about 16 square feet,” said the study’s first author Chris Madl, PhD, a postdoctoral research fellow in microbiology and immunology at Stanford, in a recent Stanford news release. In addition to taking 100-times less lab space, the new 3-D process also demands less energy and nutrients to grow the cells, he said.

A key to the development was the realization that neural stem cells need to chemically or physically remodel their surrounding environment to maintain their ability to differentiate into other cells. The researchers discovered this by creating and testing a family of gels with varying stiffness and remodeling susceptibilities. The authors explained in the paper, “Whereas cells cultured in 2-D are unrestricted and free to spread, cells within nanoporous 3-D hydrogels require matrix remodeling to spread, migrate, and proliferate.”

Surprisingly, they also discovered that the neural stem cells weren’t sensitive to the stiffness of the gel, unlike most other stem cells.

These new findings have given the leader of the research group new hope for future stem cell therapies. Sarah Heilshorn, PhD, associate professor of materials science and engineering at Stanford, said in the release, “There’s this convergence of biological knowledge and engineering principles in stem cell research that has me hopeful we might finally actually solve big problems.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Physicians urged to talk to their patients about guns

Posted October 20, 2017 by Jennifer Huber
Categories: Health

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Physicians often discuss sensitive issues such as sexual behavior and substance use with their patients. Although everyone may squirm a bit, these conversations help doctors identify health risks so they can properly counsel their patients.

Now, there is a growing movement to add guns to the exam room discussion. Many professional organizations, including the American College of Physicians, recognize that gun-related injuries and deaths are a major public health problem, not just a criminal violence issue. So they advocate that physicians speak with their patients about firearms and intervene when patients are at risk for injuring themselves or others due to firearm access.

Editors from the Annals of Internal Medicine recently wrote, “Regardless of whether one believes guns hurt people or that people hurt people with guns, we have a public health crisis and health care professionals have an obligation to do what we can to combat it.” They later added in the editorial, “Physicians and other health professionals at the frontline of patient care can help prevent firearm-related harm one patient at a time.”

Although horrifying, mass shootings account for only 1 to 2 percent of deaths from firearm violence; other incidents involving guns cause about 95 such deaths per day. Such statistics inspired Garen Wintemute, MD, a professor of emergency medicine and director of the Violence Prevention Research Program at the University of California, Davis, to research firearm violence.

In a recent article in Annals of Medicine, Wintemute explained that people who commit firearm violence — whether against others or themselves — have well-recognized risk factors that often bring them into contact with physicians. These risk factors include alcohol and substance abuse, a history of violence, suicide attempt(s), poorly controlled severe mental illness and serious life stressors, he wrote.

However, not all physicians are comfortable discussing firearms with their patients, even if they think it is appropriate. For instance, they may feel they don’t know enough about firearms. Wintemute urges doctors to educate themselves and hospitals to develop continuing education programs on the benefits and risks associated with owning and using firearms. He also urges physicians to make a public commitment to ask their patients about firearms.

There are online resources to help physicians get the conversation started. For example, the Massachusetts Medical Society has online materials and a CME course that covers practical tips on how to talk to patients about gun safety. Wintemute is also happy to provide resources and to follow-up with physicians who make the online pledge — just click the box giving him permission to contact you.

An opinion piece in the Washington Post provides some additional guidance. In the article, Stanford resident Nathanial P Morris, MD, gave practical advise to physicians that identify a patient who owns a gun and wants to self-harm or harm others. “We can pursue a range of options, from handing out gun locks to requesting family or friends temporarily hold onto firearms to asking that local police perform a welfare check at the patient’s home,” he said in the piece. “In extreme cases, if patients pose an imminent risk to themselves or others because of mental illness, we can place them on a legal hold to evaluate them in the hospital for up to 72 hours.” The goal of these actions, he wrote, is to limit patients’ access to guns to protect them from transitory suicidal or homicidal impulses. Morris added:

“ We’re not out to get anyone’s guns. We don’t wake up hoping to infringe on patients’ personal lives. But, to keep patients and communities healthy, clinicians need to be able to ask about firearms.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

How to improve care for LGBT patients

Posted October 18, 2017 by Jennifer Huber
Categories: Health

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No one facing health concerns should have to worry about receiving inequitable care because of their sexual orientation or gender identity. But studies and surveys show that many lesbian, gay, bisexual and transgender individuals experience discrimination by healthcare providers — including clinicians who refuse to provide needed care, refuse to touch them or use excessive precautions, are disrespectful or simply blame them for their health status.

Fortunately, healthcare providers can improve clinical care of their LGBT patients by taking proactive steps, as outlined in a recent viewpoint in JAMA. In particular, Alexia Torke, MD, and Jennifer Carnahan, MD, professors of medicine at the Indiana University Center for Aging Research, focus in the paper on how to optimize care for older LGBT adults, who are the first generation to be more open about their sexual orientation or gender identity.

The authors recommend that clinicians use inclusive language, such as using a patient’s preferred name and pronoun and asking about a spouse or partner regarding marital status. Forms disclosing sex should also include options for transgender patients, such as “male-to-female,” they say.

In addition, they recommend that physicians learn about the medical concerns specific to LGBT patients, such as hormone treatment and gender affirming surgery for transgender individuals. They also state that screening and diagnosis for medical conditions should be based on a person’s anatomy rather than their gender identity, giving the example that a female-to-male transgender patient is at risk of gynecologic cancers if he has not had a hysterectomy.

Torke and Carnahan also indicate that clinicians should better understand the unequal treatment that many sexual and gender minority patients face, which can have financial, social and health consequences. For instance, these individuals may not have access to health insurance due to employment discrimination or as an unrecognized spouse.

They also recommend that LGBT-friendly clinicians register as a “safe physician” with organizations like the Gay and Lesbian Medical Association.

A key to improving care for these patients is training, according to the authors and other experts. So the Human Rights Campaign has established best practices for health care organizations and provides free online training for healthcare providers.

The campaign also evaluates the implementation of these best practices and publishes an annual report. In the 2017 report, almost 600 healthcare facilities participated in the related survey and more than 900 non-participating hospitals were also researched. Happily, over 300 of the participating facilities were rated as a “leader in LGBTQ healthcare equality” with a score of 100 — including Stanford Health Care.

The authors conclude in the paper:

“Although lesbian, gay, bisexual, and transgender older adults face barriers to good health and health care, clinicians can take proactive steps to improve the care they deliver. These steps include education about prior discrimination and major health needs, as well as policies that ensure respect for the individual patients and equal treatment in all health care settings.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Stanford chemists produce chemical — originally from marine creature — needed for new drugs

Posted October 16, 2017 by Jennifer Huber
Categories: Health

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One person’s weed is another’s flower. A good example of this is spiral-tufted bryozoan, an invasive marine organism that fouls up marine environments. Although considered a pest by many, spiral-tufted bryozoan is much sought after by researchers since it can produce biostatin 1 — a chemical critical to the development of promising new drugs to treat HIV/AIDS, Alzheimer’s disease and cancer.

Although this bryozoan is abundant, bryostatin 1 is very scarce because it’s difficult to harvest from the sea creature and complex to synthesize. In fact, the National Cancer Institute’s stock of bryostatin 1 is nearly depleted from supplying over 40 clinical trials. So Stanford chemists have developed a new, easier way to synthesize bryostatin 1, as recently reported in Science.

Paul Wender, PhD, a professor of chemistry and of chemical and systems biology at Stanford, has been working for years to develop bryostatin analogs that are more effective for drug development. However, the dwindling supply of bryostatin 1 inspired him to synthesize the drug itself.

“Ordinarily, we’re in the business of making chemicals that are better than the natural products,” Wender said in a recent Stanford news release. “But when we started to realize that clinical trials a lot of people were thinking about were not being done because they didn’t have enough material, we decided, ‘That’s it, we’re going to roll up our sleeves and make bryostatin because it is now in demand.’”

The researchers devised a much simpler synthesize process, cutting the steps down from 57 to 29. They also dramatically increased the yield, making it tens of thousands of times more efficient than extracting bryostatin from spiral-tufted bryozoan and significantly more efficient than the previous synthetic approaches. And they confirmed with a wide range of tests that their synthetic bryostatin was identical to a natural sample supplied by NCI.

So far, the team has produced over two grams of bryostatin 1, and a single gram can treat about 1000 cancer patients or 2000 Alzheimer’s patients, according to their paper. After scaling up production, they expect manufacturers to produce about 20 grams per year to meet clinical and research needs, Wender said in the news release.

They also expect their work could facilitate research using bryostatin analogs derived from their synthesis process. The paper explains that these analogs “are proving to be more effective and better tolerated in comparative studies with cells, disease models in animals, and ex vivo samples taken from HIV-positive patients.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.


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