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Introduction: Communication networks among professionals can be pathways for accelerating the diffusion of innovations if some local health departments (LHDs) drive the spread of knowledge. Such a network could prove valuable during public health emergencies such as the novel coronavirus disease 2019 (COVID-19) pandemic. Our objective was to determine whether LHDs in the United States were tied together in an informal network to share information and advice about innovative community health practices, programs, and policies., Methods: In January and February 2020, we conducted an online survey of 2,303 senior LHD leaders to ask several questions about their sources of advice. We asked respondents to rank up to 3 other LHDs whose practices informed their work on new public health programs, evidence-based practices, and policies intended to improve community health. We used a social network analysis program to assess answers., Results: A total of 329 LHDs responded. An emergent network appeared to operate nationally among 740 LHDs. Eleven LHDs were repeatedly nominated by peers as sources of advice or examples (ie, opinion leaders), and 24 acted as relational bridges to hold these emergent networks together (ie, boundary spanners). Although 2 LHDs played both roles, most LHDs we surveyed performed neither of these roles., Conclusion: Opinion leading and boundary spanning health departments can be accessed to increase the likelihood of affecting the rate of interest in and adoption of innovations. Decision makers involved in disseminating new public health practices, programs, or policies may find our results useful both for emergencies and for practice-as-usual.

The coronavirus disease 2019 (COVID-19) pandemic has brought changes to the way medical care is delivered to keep health workers safe while simultaneously managing available resources. The well-being of patients and healthcare workers is crucial and has become a topic of debate as the world faces adjusts to the COVID-19 pandemic. Therefore, there is need to consider innovative methods of delivering medical care. Telehealth and digital health care which is the provision of medical care via Information Communication Technology (ICT) with highspeed telecommunications systems, has increasingly becoming popular in providing medical care services can be adopted to reduce infections during quarantine and social distancing practices. Specifically, by means of document and literature review this paper discusses the role of telehealth and digital care solutions, types and application of telehealth, and current policies for COVID-19. More importantly, findings from the article present the human, infrastructure, and institutional determinants that influence the adoption of telehealth and digital care solutions during the pandemic. The findings discuss how telehealth and digital care technologies can benefit the society. This study provides implications to informs medical staffs on the potential of digital technologies to provide support during and after the pandemic.

Our goal is to summarize the collective experience of 15 organizations in dealing with uncoordinated efforts that result in unnecessary delays in understanding, predicting, preparing for, containing, and mitigating the COVID-19 pandemic in the US. Response efforts involve the collection and analysis of data corresponding to healthcare organizations, public health departments, socioeconomic indicators, as well as additional signals collected directly from individuals and communities. We focused on electronic health record (EHR) data, since EHRs can be leveraged and scaled to improve clinical care, research, and to inform public health decision-making. We outline the current challenges in the data ecosystem and the technology infrastructure that are relevant to COVID-19, as witnessed in our 15 institutions. The infrastructure includes registries and clinical data networks to support population-level analyses. We propose a specific set of strategic next steps to increase interoperability, overall organization, and efficiencies., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

In March 2020, the World Health Organization declared the 2019 coronavirus disease (COVID-19) outbreak a pandemic, with the coronavirus disease spreading worryingly fast. In this context, information systems, digital health (electronic health, mobile health), the Internet of things, play a key role, since they can contribute to fight against COVID-19 by introducing smarter solutions to achieve a rapid control in the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes the disease. However, these technologies need a solid regulatory framework that contributes to their implementation and integration in health systems, and to improve the national response in public health. In this context, coordination between administrations and the standardization and interoperability of information are necessary. Now is the time to establish the legal and knowledge bases so that everything that has been learned and advanced is integrated into health systems, promoting safe and evidence-based use.

Introduction: Professional development is an important component of graduate medical education, but it is unclear how to best deliver this instruction. Book clubs have been used outside of medicine as a professional development tool. We sought to create and evaluate a virtual professional development book club for emergency medicine interns., Methods: We designed and implemented a virtual professional development book club during intern orientation. Afterward, participants completed an evaluative survey consisting of Likert and free-response items. Descriptive statistics were reported. We analyzed free-response data using a thematic approach., Results: Of 15 interns who participated in the book club, 12 (80%) completed the evaluative survey. Most (10/12; 83.3%) agreed or strongly agreed that the book club showed them the importance of professional development as a component of residency training and helped them reflect on their own professional (11/12; 91.7%) and personal development (11/12; 91.7%). Participants felt the book club contributed to bonding with their peers (9/12; 75%) and engagement with the residency program (9/12; 75%). Our qualitative analysis revealed five major themes regarding how the book club contributed to professional and personal development: alignment with developmental stage; deliberate practice; self-reflection; strategies to address challenges; and communication skills., Conclusion: A virtual book club was feasible to implement. Participants identified multiple ways the book club positively contributed to their professional development. These results may inform the development of other book clubs in graduate medical education.

Background: In Canada, a substantial barrier to the accessibility of surgical procedures is wait times. The objective of this study was to develop and describe an inventory of wait-time reporting systems for elective surgical procedures., Methods: Between June and August 2019, we searched all Canadian provincial and territorial ministry of health websites to identify the wait-time reporting systems in place. We conducted content analysis and used a qualitative descriptive approach to compare the variables of interest across the provinces and territories., Results: There were websites available for assessment in all 13 provinces and territories. Seven provinces have comprehensive, centralized wait-time reporting systems. The rest of the provinces have highly decentralized wait-time reporting, and the territories do not have wait-time reporting systems in place. There is substantial variation in the comprehensiveness, purpose, data sources and data collection methods among the wait-time reporting systems across the provinces and territories., Interpretation: Wait-time reporting for elective surgery in Canada is diverse, and it varies in comprehensiveness across the provinces and territories. The present findings can help direct future investigations of Canadian reporting systems, which would provide useful information for policy-makers and those interested in reducing wait times in Canada., Competing Interests: Competing interests: None declared., (Copyright 2020, Joule Inc. or its licensors.)

The firearms data infrastructure in the United States is severely limited in scope and fragmented in nature. Improved data systems are needed in order to address gun violence and promote productive conversation about gun policy. In the absence of federal leadership in firearms data systems improvement, motivated states may take proactive steps to stitch gaps in data systems. We propose that states evaluate the gaps in their systems, expand data collection, and improve data presentation and availability.

Introduction: Sickle cell disease (SCD) is a complex, chronic disease caused by abnormal polymerization of hemoglobin, which leads to severe pain episodes, fatigue, and end-organ damage. Patient reported outcomes (PROs) have emerged as a critical tool for measuring SCD disease severity and response to treatment., Areas Covered: Authors review the key issues involved when deciding to use a PRO in a clinical trial. We describe the most highly recommended generic and disease-specific PRO tools in SCD and discuss the challenges of incorporating them in clinical practice., Expert Opinion: PRO measures are essential to incorporate into SCD clinical trials either as primary or secondary outcomes. The use of PRO measures in SCD facilitates a patient-centered approach, which is likely to lead to improved outcomes. Significant challenges remain in adapting PRO tools to routine clinical use and in developing countries.

Background: Health service delivery indicators are designed to reveal how well health services meet a community's needs. Effective use of the data can enable targeted improvements in health service delivery. We conducted a systematic review to identify the factors that influence the use of health service delivery indicators to improve delivery of primary health care services in low- and middle-income settings., Methods: We reviewed empirical studies published in 2005 or later that provided evidence on the use of health service delivery data at the primary care level in low- and middle-income countries. We searched Scopus, Medline, the Cochrane Library, and citations of included studies. We also searched the gray literature, using a separate strategy. We extracted information on study design, setting, study population, study objective, key findings, and any identified lessons learned., Results: Twelve studies met the inclusion criteria. This small number of studies suggests there is insufficient evidence to draw reliable conclusions. However, a content analysis identified the following potentially influential factors, which we classified into 3 categories: governance (leadership, participatory monitoring, regular review of data); production of information (presentation of findings, data quality, qualitative data); and health information system resources (electronic health management information systems, organizational structure, training). Contextual factors and performance-based financing were also each found to have a role; however, discussing these as mediating factors may not be practical in terms of promoting data use., Conclusion: Scant evidence exists regarding factors that influence the use of health service delivery indicators to improve delivery of primary health care services in low- and middle-income countries. However, the existing evidence highlights some factors that may have a role in improving data use. Further research may benefit from comparing data use factors across different types of program indicators or using our classification as a framework for field experiments., (© Rendell et al.)

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.

The early 2020 response to COVID-19 revealed major gaps in public health systems around the world as many were overwhelmed by a quickly-spreading new coronavirus. While the critical task at hand is turning the tide on COVID-19, this pandemic serves as a clarion call to governments and citizens alike to ensure public health systems are better prepared to meet the emergencies of the future, many of which will be climate-related. Learning from the successes as well as the failures of the pandemic response provides some guidance. We apply several recommendations of a recent World Health Organization Policy Brief on COVID-19 response to 5 key areas of public health systems - governance, information, services, determinants, and capacity - to suggest early lessons from the coronavirus pandemic for climate change preparedness. COVID-19 has demonstrated how essential public health is to well-functioning human societies and how high the economic cost of an unprepared health system can be. This pandemic provides valuable early warnings, with lessons for building public health resilience.

Digital health interventions are globally playing a significant role to combat coronavirus disease 2019 (COVID-19), which is an infectious disease caused by Severe Acute Respiratory Syndrome coronavirus 2. Here, we present a very brief overview of the multifaceted digital interventions, globally, and in India, for maintaining health and health-care delivery, in the context of the Covid-19 pandemic., Competing Interests: None

Background: Heat wave early warning systems help alert decision-makers and the public to prepare for hot weather and implement preventive actions to protect health. Prior to harmonization, public health units across Ontario either used independent systems with varying methodologies for triggering and issuing public heat warnings or did not use any system. The federal government also issued heat warnings based on different criteria. During heat events, adjacent public health units in Ontario and the federal government would routinely call heat warnings at different times with separate public messages, leading to confusion. This article describes the collaborative process and key steps in developing a harmonized Heat Warning and Information System (HWIS) for Ontario., Setting: Public health units across Ontario, Canada, collaborated with the federal and provincial government to develop the harmonized HWIS for Ontario., Intervention: In 2011, stakeholders identified the need to develop a harmonized system across Ontario to improve heat warning services, warning criteria, and health messaging. Through a 5-year process facilitated by a non-governmental organization, the three levels of government collaborated to establish the Ontario HWIS., Outcomes: The province-wide HWIS was implemented in 2016 with the Ontario Ministry of Health and Long-Term Care's release of the harmonized HWIS Standard Operating Practice, which outlined the notification and warning process., Implications: The lessons learned could help spur action in other provinces and jurisdictions internationally in the development of similar health evidence-based warning systems, including in particular those for protecting public health during extreme heat events.

Background: Despite a growing need for designing and monitoring health information sites through comprehensive examination of the various elements of website quality, there is little research that systematically models and presents such examinations., Objectives: Applying the updated DeLone and McLean Model of Information Systems Success, this research aimed to examine how health information sites' information quality, system quality, and service quality lead to user satisfaction and perceived benefits., Methods: This research was conducted in a specific context of the National Health Information Portal (NHIP), a governmental health information site in South Korea. We conducted online survey in 2017, with 506 adults from the NHIP consumer panel. Data were analyzed using a confirmatory factor analysis, hierarchical ordinary least squares regression, and bootstrapping approach for a mediation test., Results: Of the three quality factors, information quality had significant associations with all outcome variables: user satisfaction, intention to reuse the site, and perceived benefits of site use in health settings. There were also indirect paths from information quality to perceived benefits, one mediated through intention and the other mediated through satisfaction and then intention. Service quality had a significant association with user satisfaction, and its impact on perceived benefits occurred indirectly through user satisfaction and intention in serial. By contrast, the role of system quality received no empirical support., Implications: The results offer theoretical and practical implications for how to enhance the effectiveness of online health information sites., Competing Interests: Declaration of Competing Interest The authors declare there are no conflicts of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Saudi Arabia has invested heavily in its health care system by establishing health care infrastructures to improve health of the nation. However, it remains to be seen whether it is efficient and effective in providing health care services needed. Primary health care, which is the basis of universal health coverage, needs to be assessed on its performance, challenges and future opportunities to serve the Saudi Arabian population., Aims: This review aimed to identify challenges within the Saudi Arabian health care system with a focus on primary health care services, and to analyse the interrelated factors in order to suggest remedial reforms to further strengthen and improve the health care system., Methods: A narrative review of previous studies and governmental reports was undertaken to extract, analyse, synthesize and report the findings., Results: The review found a number of key areas for improvement in the primary health care system. These areas include: the scope, structure, infrastructure, financing, increased demand, increased costs and workforce capacity. Other critical challenges include inequitable access to health services, quality and safety of services, the growing burden of chronic diseases, lack of an effective information system, management and leadership issues, and gaps in the referral system., Conclusion: The Saudi Arabian health care system needs comprehensive reform with a focus on primary health care., (Copyright © World Health Organization (WHO) 2020. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo).)

The recent rise in cybersecurity breaches in healthcare organizations has put patients' privacy at a higher risk of being exposed. Despite this threat and the additional danger posed by such incidents to patients' safety, as well as operational and financial threats to healthcare organizations, very few studies have systematically examined the cybersecurity threats in healthcare. To lay a firm foundation for healthcare organizations and policymakers in better understanding the complexity of the issue of cybersecurity, this study explores the major type of cybersecurity threats for healthcare organizations and explains the roles of the four major players (cyber attackers, cyber defenders, developers, and end-users) in cybersecurity. Finally, the paper discusses a set of recommendations for the policymakers and healthcare organizations to strengthen cybersecurity in their organization.

The smart health medical system is expected to enhance the quality of health care services significantly. These system keeps patients related record and provides the services over the insecure public channel which may cause data security and privacy concerns in a smart health system. On the other hand, ciphertext attribute-based encryption(CP-ABE) provides possible encrypted data security. There are some security flaws in CP-ABE, where the existing access policies are in the cleartext form for accessing encrypted sensitive data. On the other hand, it supports the small attribute universe, which restricts the practical deployments of CP-ABE. Moreover, outsider adversary observed the communication, which also creates a serious threat to CP-ABE model. To overcome security and privacy risk, efficient access control have been designed and devolved for medical services. Although we also demonstrate the security analysis of Zhang et al.'s scheme, which is vulnerable to inefficient security proof and man in the middle attack. In the proposed scheme, we proposed an efficient and security preserve scheme to overcome the weaknesses of Zhang's et al.'s system. The protocol satisfies the attribute values of the medical user with hidden access policies. It has been proved under the standard model, which ensure the security of the protocol. Moreover, performance analysis comparison shows that the proposed scheme is more efficient than the existing one.

Background: The medical alliance and telemedicine are considered to be important means to solve the imbalance between regions and shortage of professionals and promote the homogenization of medical services. Sichuan Provincial People's Hospital Group (SPPHG) is a network of hospitals with different levels of expertise, and all the members with radiotherapy form a radiotherapy network (RTN). Addressing the inadequacy and imbalance of radiotherapy services of Sichuan Province, China, a tele-radiotherapy system for RTN-SPPHG is designed, which includes the business model and corresponding technical implementation of an information system. Materials and Methods: In the RTN-SPPHG, a distributed remote collaboration business model is explored and a tele-radiotherapy information system is customized for this telemedicine model. Both the business model and tailored information system were evaluated in actual use. Results: Based on the tele-radiotherapy system of RTN-SPPHG, multitype hospitals are linked together and serve as a whole. Through the internet, the experience of experts of Sichuan Provincial People's Hospital is effectively deployed to member hospitals at the grassroot level. Conclusions: A close-knit medical alliance based on a tele-radiotherapy system should be a way to rapidly improve radiotherapy services and promote the homogenization of service in a region.

A shift in healthcare payment models from volume toward value-based incentives will require deliberate input into systems development from both perioperative clinicians and administrators to ensure appropriate recognition of the value of all services provided-particularly ones that are not reimbursable in current fee-for-service payment models. Time-driven activity-based costing (TDABC) methodology identifies cost drivers and reduces inaccurate costing based on siloed budgets. Inaccurate costing also results from the fact that current costing methods use charges and there has been tremendous cost shifting throughout health care. High cost, high variability processes can be identified for process improvement. As payment models inevitably evolve towards value-based metrics, it will be critical to knowledgably participate in the coordination of these changes. This document provides 8 practical Recommendations from the Society for Perioperative Assessment and Quality Improvement (SPAQI) aimed at outlining the principles of TDABC, creating process maps for patient workflows, understanding payment structures, establishing physician alignment across service lines to create integrated practice units to facilitate development of evidence-based pathways for specific patient risk groups, establishing consistent care delivery, minimizing variability between physicians and departments, utilizing data analytics and information technology tools to track progress and obtain actionable data, and using TDABC to create costing transparency.

Heterogeneity of people with diabetes makes maintaining blood glucose control and achieving therapy adherence a challenge. It is fundamental that patients get actively involved in the management of the disease in their living environments. The objective of this paper is to evaluate the use and acceptance of a self-management system for diabetes developed with User Centered Design Principles in community settings. Persons with diabetes and health professionals were involved the design, development and evaluation of the self-management system; which comprised three iterative cycles: scenario definition, user archetype definition and system development. A comprehensive system was developed integrating modules for the management of blood glucose levels, medication, food intake habits, physical activity, diabetes education and messaging. The system was adapted for two types of principal users (personas): Type 1 Diabetes user and Type 2 Diabetes user. The system was evaluated by assessing the use, the compliance, the attractiveness and perceived usefulness in a multicenter randomized pilot study involving 20 patients and 24 treating professionals for a period of four weeks. Usage and compliance of the co-designed system was compared during the first and the last two weeks of the study, showing a significantly improved behaviour of patients towards the system for each of the modules. This resulted in a successful adoption by both type of personas. Only the medication module showed a significantly different use and compliance (p= 0.01) which can be explained by the different therapeutic course of the two types of diabetes. The involvement of patients to make their own decisions and choices form design stages was key for the adoption of a self-management system for diabetes.

The technology of Internet of Things (IoT) has appealed to both professionals and the general public to its convenience and flexibility. As a crucial application of IoT, telecare medicine information system (TMIS) provides people a high quality of life and advanced level of medical service. In TMIS, smart card-based authenticated key agreement schemes for multi-server architectures have gathered momentum and positive impetus due to the conventional bound of a single server. However, we demonstrate that most of the protocols in the literatures can not implement strong security features in TMIS, such as Lee et al.'s and Shu's scheme. They store the identity information directly, which fail to provide strong anonymity and suffer from password guessing attack. Then we propose an extended authenticated key agreement scheme (short for AKAS) with strong anonymity for multi-server environment in TMIS, by enhancing the security of the correlation parameters stored in the smart cards and calculating patients' dynamic identities. Furthermore, the proposed chaotic map-based scheme provides privacy protection and is formally proved under Burrows-Abadi-Needham (BAN) logic. At the same, the informal security analysis attests that the AKAS scheme not only could resist the multifarious security attacks but also improve efficiency by 21% compared with Lee et al.'s and Shu's scheme.

Blockchain in healthcare applications requires robust security and privacy mechanism for high-level authentication, interoperability and medical records sharing to comply with the strict legal requirements of the Health Insurance Portability and Accountability Act of 1996. Blockchain technology in the healthcare industry has received considerable research attention in recent years. This study conducts a review to substantially analyse and map the research landscape of current technologies, mainly the use of blockchain in healthcare applications, into a coherent taxonomy. The present study systematically searches all relevant research articles on blockchain in healthcare applications in three accessible databases, namely, ScienceDirect, IEEE and Web of Science, by using the defined keywords 'blockchain', 'healthcare' and 'electronic health records' and their variations. The final set of collected articles related to the use of blockchain in healthcare application is divided into three categories. The first category includes articles (i.e. 43/58 scientific articles) that attempted to develop and design healthcare applications integrating blockchain, particularly those on new architecture, system designs, framework, scheme, model, platform, approach, protocol and algorithm. The second category includes studies (i.e., 6/58 scientific articles) that attempted to evaluate and analyse the adoption of blockchain in the healthcare system. Finally, the third category comprises review and survey articles (i.e., 6/58 scientific articles) related to the integration of blockchain into healthcare applications. The final articles for review are discussed on the basis of five aspects: (1) year of publication, (2) nationality of authors, (3) publishing house or journal, (4) purpose of using blockchain in health applications and the corresponding contributions and (5) problem types and proposed solutions. Additionally, this study provides identified motivations, open challenges and recommendations on the use of blockchain in healthcare applications. The current research contributes to the literature by providing a detailed review of feasible alternatives and identifying the research gaps. Accordingly, researchers and developers are provided with appealing opportunities to further develop decentralised healthcare applications through a comprehensive discussion of about the importance of blockchain and its integration into various healthcare applications.

Background: Interest in value-based healthcare, generally defined as providing better care at lower cost, has grown worldwide, and learning health systems (LHSs) have been proposed as a key strategy for improving value in healthcare. LHSs are emerging around the world and aim to leverage advancements in science, technology and practice to improve health system performance at lower cost. However, there remains much uncertainty around the implementation of LHSs and the distinctive features of these systems. This paper presents a conceptual framework that has been developed in Canada to support the implementation of value-creating LHSs., Methods: The framework was developed by an interdisciplinary team at the Institut national d'excellence en santé et en services sociaux (INESSS). It was informed by a scoping review of the scientific and grey literature on LHSs, regular team discussions over a 14-month period, and consultations with Canadian and international experts., Results: The framework describes four elements that characterise LHSs, namely (1) core values, (2) pillars and accelerators, (3) processes and (4) outcomes. LHSs embody certain core values, including an emphasis on participatory leadership, inclusiveness, scientific rigour and person-centredness. In addition, values such as equity and solidarity should also guide LHSs and are particularly relevant in countries like Canada. LHS pillars are the infrastructure and resources supporting the LHS, whereas accelerators are those specific structures that enable more rapid learning and improvement. For LHSs to create value, such infrastructures must not only exist within the ecosystem but also be connected and aligned with the LHSs' strategic goals. These pillars support the execution, routinisation and acceleration of learning cycles, which are the fundamental processes of LHSs. The main outcome sought by executing learning cycles is the creation of value, which we define as the striking of a more optimal balance of impacts on patient and provider experience, population health and health system costs., Conclusions: Our framework illustrates how the distinctive structures, processes and outcomes of LHSs tie together with the aim of optimising health system performance and delivering greater value in health systems.

Big data analytics enables large-scale data sets integration, supporting people management decisions, and cost-effectiveness evaluation of healthcare organizations. The purpose of this article is to address the decision-making process based on big data analytics in Healthcare organizations, to identify main big data analytics able to support healthcare leaders' decisions and to present some strategies to enhance efficiency along the healthcare value chain. Our research was based on a systematic review. During the literature review, we will be presenting as well the different applications of big data in the healthcare context and a proposal for a predictive model for people management processes. Our research underlines the importance big data analytics can add to the efficiency of the decision-making process, through a predictive model and real-time analytics, assisting in the collection, management, and integration of data in healthcare organizations.

The 2017-2018 influenza season was associated with high demand for both emergency department (ED) care and inpatient acute care for influenza-like illness (ILI). This high demand resulted in increased numbers of inpatients and ED patients, including prolonged ED length of stay. A large, urban, academic medical center in a cold-weather region was limited in its ability to expand its footprint to create de novo locations of care, such as temporary outbuildings or tents. As such, a large conference room was rapidly converted and placed in service as a temporary inpatient unit for adults requiring inpatient admission. LOGISTICS AND IMPLEMENTATION: The logistical, infection prevention, safety, information technology, staffing, and other concerns of creating a clinical environment during a high demand scenario is challenging. However, the lessons learned in this study are reproducible despite the complexity of this issue. CONCLUSION: This is believed to be the first published account of successful conversion of a nonclinical area to an operational clinical unit in response to a surge in demand for hospital care and admission. This may be a valid option for hospitals of all sizes as part of a surge or disaster plan., (Copyright © 2019 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Background: Public reporting of provider performance currently encompasses a range of measures of quality, cost, and patient experience of care. However, little is known about how medical groups use measures for performance improvement. This information could help medical groups undertake internal measurement while helping payers, policy makers, and measurement experts develop more useful publicly reported measures and quality improvement strategies., Methods: An exploratory, qualitative study was conducted of ambulatory care medical groups across the United States that currently gather their own performance data., Results: Eighty-three interviews were conducted with 91 individuals representing 37 medical groups. Findings were distilled into three major themes: (1) measures used internally, (2) strategies for using internal measurement for performance improvement, and (3) other uses of internal measurement. Medical groups used both clinical and business process measures, including measures from external measure sets and internally derived measures. Strategies for using internal measurement for quality improvement included taking a gradual, iterative approach and setting clear goals with high priority, finding workable approaches to data sharing, and fostering engagement by focusing on actionable measures. Measurement was also used to check accuracy of external performance reports, clarify and manage conflicting external measurement requirements, and prepare for anticipated external measurement requirements. Respondents in most groups did not report a need to assess costs of internal measurement or the capacity to do so., Conclusion: Despite challenges and barriers, respondents found great value in conducting internal measurement. Their experiences may provide valuable lessons and knowledge for medical group leaders in earlier stages of establishing internal measurement programs., (Copyright © 2019 The Joint Commission. All rights reserved.)

In 2018, the Society for Epidemiologic Research and its partner journal, the American Journal of Epidemiology, assembled a working group to develop a set of papers devoted to the "future of epidemiology." These 14 papers covered a wide range of topic areas and perspectives, from thoughts on our profession, teaching, and methods to critical areas of substantive research. The authors of those papers considered current challenges and future opportunities for research and education. In light of past commentaries, 4 papers also include reflections on the discipline at present and in the future., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Concern among the public and policymakers about current and future major staff shortages is increasing. Strengthening Human Resource (HR) practices and adopting HR technologies such as Human Resource Information Systems (HRIS), that can collect, store and report workforce data are often described as a potential solution to this problem. Indeed, examples from other industries show that HRIS can help to launch or manage, as well as provide ongoing insights concerning the whole career cycle of an employee. However, few of the existing studies that discuss technology or its impacts on the future of work have focused on health organizations, and those that do have not received sufficient attention in health literature. Furthermore, such contributions as there have been have either prioritized a particular type of technology or focused mainly on the effect of automation on health professionals' work. They have thus overlooked the full range of possible uses of these technologies and, specifically, have neglected the topic of HR for Health (HRH) management in health organizations. The primary aim of this paper is to address this lacuna, with specific reference to the existing categorization of HR technological disruptions. To conclude, health organizations and the health and HR professionals who work within them need to use HRIS responsibly, finding a balance between the drive for innovation, productivity and efficiency and respect for all potential legal, ethical and compliance issues, as well as taking account of the importance of HRH wellbeing and satisfaction.

Advances in technology make it possible to supplement in-person teaching activities with digital learning, use electronic records in patient care, and communicate through social media. This relatively new "digital learning environment" has changed how medical trainees learn, participate in patient care, are assessed, and provide feedback. Communication has changed with the use of digital health records, the evolution of interdisciplinary and interprofessional communication, and the emergence of social media. Learning has evolved with the proliferation of online tools such as apps, blogs, podcasts, and wikis, and the formation of virtual communities. Assessment of learners has progressed due to the increasing amounts of data being collected and analyzed. Digital technologies have also enhanced learning in resource-poor environments by making resources and expertise more accessible. While digital technology offers benefits to learners, the teachers, and health care systems, there are concerns regarding the ownership, privacy, safety, and management of patient and learner data. We highlight selected themes in the domains of digital communication, digital learning resources, and digital assessment and close by providing practical recommendations for the integration of digital technology into education, with the aim of maximizing its benefits while reducing risks.

There is a synergistic relationship between analog field testing and the deep space telecommunication capabilities necessary for future human exploration. The BASALT (Biologic Analog Science Associated with Lava Terrains) research project developed and implemented a telecommunications architecture that serves as a high-fidelity analog of future telecommunication capabilities for Mars. This paper presents the architecture and its constituent elements. The rationale for the various protocols and radio frequency (RF) link types required to enable an interdisciplinary field mission are discussed, and the performance results from the BASALT field tests are provided. Extravehicular Informatics Backpacks (EVIB) designed for BASALT and tested by human subjects are also discussed, and the proceeding sections show how these prototype extravehicular activity (EVA) information systems can augment future human exploration. The paper concludes with an aggregate analysis of the data product types and data volumes generated, transferred, and utilized by the ground team and explorers over the course of the field deployments.

Background: Due to environmental factors such as nutrient intake imbalance, lack of exercise, and increased stress, it is necessary to control nutrition in order to prevent diseases and provide treatment in terms of healthcare., Objective: This study proposes the activity-based nutrition management model with the use of the cluster analysis of similar group for healthcare., Methods: The proposed method is to conduct the cluster analysis of similar group for nutrition management and to develop the real-time activity information based nutrition management algorithm with the use of big data in order to improve the quality of healthcare management service. It is to re-process an existing nutrition database and add voice recognition function in line with the service so as to improve convenience of intake-food inputs. In addition, the Bluetooth Low Energy (BLE) communication based standard collection of bio signals occurring in real-time is developed. This study also proposes the method of improving an existing algorithm of drawing a daily recommended allowance with the use of real-time activity information, and the proposed service provides the essential information of nutrition management with the use of public big data., Results: To verify the developed technology and service model and its effectiveness, the nutrition management service system is designed and developed with human interface., Conclusions: The developed health model helps to solve the obesity problem, save medical costs, and address the issue of national health.

Background: Barriers to EMS care can result in suboptimal outcomes and preventable morbidity and mortality. Large EMS databases such as the National Emergency Medical Services Information System (NEMSIS) dataset provide valuable data on the relative incidence of such barriers to care., Methods: A retrospective cross-sectional analysis was performed using the NEMSIS database. Cases of violent trauma were collected based on gender and racial group. Each group was analyzed for the ratio of cases that involved an EMS barrier to care. Chi-square testing was used to assess associations, and the relative risk was used as the measure of strength of association. For all tests, statistical significance was set at the 0.05 level., Results: 719,812 cases of violent trauma were analyzed using the NEMSIS dataset. EMS encountered barriers to care for white and non-white patients was found to be 4.9% and 4.0% respectively. The difference between groups was found to be 0.9% (95% CI [0.7%, 1.1%] p < 0.0001). RR was 1.23 for white patients (95% CI [1.19, 1.26]), and 0.82 (95% CI [0.79, 0.84]) for non-white. EMS barriers to care for male and female patients was found to be 6.03% and 3.34%, respectively. The difference between groups was found to be 2.7% (95% CI [2.6%, 2.8%] p < 0.0001). RR for male patients was 1.80 (95% Cl [1.76, 1.84]) while RR for female patients was 0.55 (95% CI [0.54, 0.57])., Conclusions: Racially white patients and male patients have a statistically significant higher risk of encountering an EMS barrier to care in cases of violent trauma., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The opioid overdose crisis now claims more than 40,000 lives in the United States every year, and many hospitals and health systems are responding with opioid-related initiatives, but how best to coordinate hospital or health system-wide strategy and approach remains a challenge., Methods: An organizational opioid stewardship program (OSP) was created to reduce opioid-related morbidity and mortality in order to provide an efficient, comprehensive, multidisciplinary approach to address the epidemic in one health system. An executive committee of hospital leaders was convened to empower and launch the program. To measure progress, metrics related to care of patients on opioids and those with opioid use disorder (OUD) were evaluated., Results: The OSP created a holistic, health system-wide program that addressed opioid prescribing, treatment of OUD, education, and information technology tools. After implementation, the number of opioid prescriptions decreased (-73.5/month; p < 0.001), mean morphine milligram equivalents (MME) per prescription decreased (-0.4/month; p < 0.001), the number of unique patients receiving an opioid decreased (-52.6/month; p < 0.001), and the number of prescriptions ≥ 90 MME decreased (-48.1/month; p < 0.001). Prescriptions and providers for buprenorphine increased (+6.0 prescriptions/month and +0.4 providers/month; both p < 0.001). Visits for opioid overdose did not change (-0.2 overdoses/month; p = 0.29)., Conclusion: This paper describes a framework for a new health system-wide OSP. Successful implementation required strong executive sponsorship, ensuring that the program is not housed in any one clinical department in the health system, creating an environment that empowers cross-disciplinary collaboration and inclusion, as well as the development of measures to guide efforts., (Copyright © 2018 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Heterogeneous mobile authentication is a crucial technique to securely retrieve the resource of e-healthcare cloud servers which are commonly implemented in a public key Infrastructure (PKI). Conventionally, a mobile data user can utilize a self-chosen password along with a portable device to request the access privilege of clouds. However, to validate the membership of users, a cloud server usually has to make use of a password table, which not only increases the burden of management, but also raises the possibility of information leakage. In this paper, we propose a secure heterogeneous mobile authentication and key agreement scheme for e-healthcare cloud systems. In our system structure, an e-healthcare cloud server of traditional PKIs does not have to store a password table. A legitimate data user only possesses a security token hardware and keeps an offline updatable password without using any private key. Our scheme is classified into the category of dynamic ID authentication techniques, since a data user is able to preserve his/her anonymity during authentication processes. We formally prove that the proposed mechanism fulfills the essential authenticated key exchange (AKE) security and owns lower computational costs. To further ensure the practical application security, an automatic security validation tool called AVISPA is also adopted to analyze possible attacks and pitfalls of our designed protocol., Competing Interests: The authors have declared that no competing interests exist.

We develop a general framework for optimal health policy design in a dynamic setting. We consider a hypothetical medical intervention for a cohort of patients where one parameter varies across cohorts with imperfectly observable linear dynamics. We seek to identify the optimal time to change the current health intervention policy and the optimal time to collect decision-relevant information. We formulate this problem as a discrete-time, infinite-horizon Markov decision process and we establish structural properties in terms of first and second-order monotonicity. We demonstrate that it is generally optimal to delay information acquisition until an effect on decisions is sufficiently likely. We apply this framework to the evaluation of hepatitis C virus (HCV) screening in the general population determining which birth cohorts to screen for HCV and when to collect information about HCV prevalence.

Background: The Arden Syntax is a knowledge-encoding standard, started in 1989, and now in its 10th revision, maintained by the health level seven (HL7) organization. It has constructs borrowed from several language concepts that were available at that time (mainly the HELP hospital information system and the Regenstrief medical record system (RMRS), but also the Pascal language, functional languages and the data structure of frames, used in artificial intelligence). The syntax has a rationale for its constructs, and has restrictions that follow this rationale. The main goal of the Standard is to promote knowledge sharing, by avoiding the complexity of traditional programs, so that a medical logic module (MLM) written in the Arden Syntax can remain shareable and understandable across institutions., Objectives: One of the restrictions of the syntax is that you cannot define your own functions and subroutines inside an MLM. An MLM can, however, call another MLM, where this MLM will serve as a function. This will add an additional dependency between MLMs, a known criticism of the Arden Syntax knowledge model. This article explains why we believe the Arden Syntax would benefit from a construct for user-defined functions, discusses the need, the benefits and the limitations of such a construct., Methods and Materials: We used the recent grammar of the Arden Syntax v.2.10, and both the Arden Syntax standard document and the Arden Syntax Rationale article as guidelines. We gradually introduced production rules to the grammar. We used the CUP parsing tool to verify that no ambiguities were detected., Results: A new grammar was produced, that supports user-defined functions. 22 production rules were added to the grammar. A parser was built using the CUP parsing tool. A few examples are given to illustrate the concepts. All examples were parsed correctly., Conclusions: It is possible to add user-defined functions to the Arden Syntax in a way that remains coherent with the standard. We believe that this enhances the readability and the robustness of MLMs. A detailed proposal will be submitted by the end of the year to the HL7 workgroup on Arden Syntax., (Copyright © 2015 Elsevier B.V. All rights reserved.)

The Arden Syntax originated in the 1980's, when several knowledge-based systems began to show promise, but researchers recognized the burden of recreating these systems at every institution. Derived initially from Health Evaluation through Logical Processing (HELP) and the Regenstrief Medical Record System (RMRS), the Arden Syntax defines medical logic that can be encoded as independent rules, such as reminders and alerts, with the hope of creating a public library of rules. It was first vetted at an informatics retreat held in 1989 at Columbia University's Arden Homestead. The syntax was intended to be readable by clinician experts but to provide powerful array processing, which was derived largely a programming language called APL. The syntax was improved and implemented by a number of researchers and vendors in the early 1990's and was initially adopted by the consensus standards organization, the American Society for Testing and Materials., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Objective: The objective of this study is to help a team of physicians and knowledge engineers acquire clinical knowledge from existing practices datasets for treatment of head and neck cancer, to validate the knowledge against published guidelines, to create refined rules, and to incorporate these rules into clinical workflow for clinical decision support., Methods and Materials: A team of physicians (clinical domain experts) and knowledge engineers adapt an approach for modeling existing treatment practices into final executable clinical models. For initial work, the oral cavity is selected as the candidate target area for the creation of rules covering a treatment plan for cancer. The final executable model is presented in HL7 Arden Syntax, which helps the clinical knowledge be shared among organizations. We use a data-driven knowledge acquisition approach based on analysis of real patient datasets to generate a predictive model (PM). The PM is converted into a refined-clinical knowledge model (R-CKM), which follows a rigorous validation process. The validation process uses a clinical knowledge model (CKM), which provides the basis for defining underlying validation criteria. The R-CKM is converted into a set of medical logic modules (MLMs) and is evaluated using real patient data from a hospital information system., Results: We selected the oral cavity as the intended site for derivation of all related clinical rules for possible associated treatment plans. A team of physicians analyzed the National Comprehensive Cancer Network (NCCN) guidelines for the oral cavity and created a common CKM. Among the decision tree algorithms, chi-squared automatic interaction detection (CHAID) was applied to a refined dataset of 1229 patients to generate the PM. The PM was tested on a disjoint dataset of 739 patients, which gives 59.0% accuracy. Using a rigorous validation process, the R-CKM was created from the PM as the final model, after conforming to the CKM. The R-CKM was converted into four candidate MLMs, and was used to evaluate real data from 739 patients, yielding efficient performance with 53.0% accuracy., Conclusion: Data-driven knowledge acquisition and validation against published guidelines were used to help a team of physicians and knowledge engineers create executable clinical knowledge. The advantages of the R-CKM are twofold: it reflects real practices and conforms to standard guidelines, while providing optimal accuracy comparable to that of a PM. The proposed approach yields better insight into the steps of knowledge acquisition and enhances collaboration efforts of the team of physicians and knowledge engineers., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Objective: Arden Syntax is a standard for representing and sharing medical knowledge in form of independent modules and looks back on a history of 25 years. Its traditional field of application is the monitoring of clinical events such as generating an alert in case of occurrence of a critical laboratory result. Arden Syntax Medical Logic Modules must be able to retrieve patient data from the electronic medical record in order to enable automated decision making. For patient data with a simple structure, for instance a list of laboratory results, or, in a broader view, any patient data with a list or table structure, this mapping process is straightforward. Nevertheless, if patient data are of a complex nested structure the mapping process may become tedious. Two clinical requirements - to process complex microbiology data and to decrease the time between a critical laboratory event and its alerting by monitoring Health Level 7 (HL7) communication - have triggered the investigation of approaches for providing complex patient data from electronic medical records inside Arden Syntax Medical Logic Modules., Methods and Materials: The data mapping capabilities of current versions of the Arden Syntax standard as well as interfaces and data mapping capabilities of three different Arden Syntax environments have been analyzed. We found and implemented three different approaches to map a test sample of complex microbiology data for 22 patients and measured their execution times and memory usage. Based on one of these approaches, we mapped entire HL7 messages onto congruent Arden Syntax objects., Results: While current versions of Arden Syntax support the mapping of list and table structures, complex data structures are so far unsupported. We identified three different approaches to map complex data from electronic patient records onto Arden Syntax variables; each of these approaches successfully mapped a test sample of complex microbiology data. The first approach was implemented in Arden Syntax itself, the second one inside the interface component of one of the investigated Arden Syntax environments. The third one was based on deserialization of Extended Markup Language (XML) data. Mean execution times of the approaches to map the test sample were 497ms, 382ms, and 84ms. Peak memory usage amounted to 3MB, 3MB, and 6MB., Conclusion: The most promising approach by far was to map arbitrary XML structures onto congruent complex data types of Arden Syntax through deserialization. This approach is generic insofar as a data mapper based on this approach can transform any patient data provided in appropriate XML format. Therefore it could help overcome a major obstacle for integrating clinical decision support functions into clinical information systems. Theoretically, the deserialization approach would even allow mapping entire patient records onto Arden Syntax objects in one single step. We recommend extending the Arden Syntax specification with an appropriate XML data format., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Background: The initial version of the Arden Syntax for Medical Logic Systems was created to facilitate explicit representation of medical logic in a form that could be easily composed and interpreted by clinical experts in order to facilitate clinical decision support (CDS). Because of demand from knowledge engineers and programmers to improve functionality related to complex use cases, the Arden Syntax evolved to include features typical of general programming languages but that were specialized to meet the needs of the clinical decision support environment, including integration into a clinical information system architecture., Method: Review of the design history and evolution of the Arden Syntax by workers who participated in this evolution from the perspective of the standards development organization (SDO)., Results: In order to meet user needs, a variety of features were successively incorporated in Arden Syntax. These can be grouped in several classes of change, including control flow, data structures, operators and external links. These changes included expansion of operators to manipulate lists and strings; a formalism for structured output; iteration constructs; user-defined objects and operators to manipulate them; features to support international use and output in different natural languages; additional control features; fuzzy logic formalisms; and mapping of the entire syntax to XML. The history and rationale of this evolution are summarized., Conclusion: In response to user demand and to reflect its growing role in clinical decision support, the Arden Syntax has evolved to include a number of powerful features. These depart somewhat from the original vision of the syntax as simple and easily understandable but from the SDO perspective increase the utility of this standard for implementation of CDS. Backwards compatibility has been maintained, allowing continued support of the earlier, simpler decision support models., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Introduction: Arden Syntax is a Health Level Seven International (HL7) standard language that is used for representing medical knowledge as logic statements. Arden Syntax Markup Language (ArdenML) is a new representation of Arden Syntax based on XML. Compilers are required to execute medical logic modules (MLMs) in the hospital environment. However, ArdenML may also replace the compiler. The purpose of this study is to demonstrate that MLMs, encoded in ArdenML, can be transformed into a commercial rule engine format through an XSLT stylesheet and made executable in a target system., Methods: The target rule engine selected was Blaze Advisor. We developed an XSLT stylesheet to transform MLMs in ArdenML into Structured Rules Language (SRL) in Blaze Advisor, through a comparison of syntax between the two languages. The stylesheet was then refined recursively, by building and applying rules collected from the billing and coding guidelines of the Korean health insurance service. Two nurse coders collected and verified the rules and two information technology (IT) specialists encoded the MLMs and built the XSLT stylesheet. Finally, the stylesheet was validated by importing the MLMs into Blaze Advisor and applying them to claims data., Results: The language comparison revealed that Blaze Advisor requires the declaration of variables with explicit types. We used both integer and real numbers for numeric types in ArdenML. "IF∼THEN" statements and assignment statements in ArdenML become rules in Blaze Advisor. We designed an XSLT stylesheet to solve this issue. In addition, we maintained the order of rule execution in the transformed rules, and added two small programs to support variable declarations and action statements. A total of 1489 rules were reviewed during this study, of which 324 rules were collected. We removed duplicate rules and encoded 241 unique MLMs in ArdenML, which were successfully transformed into SRL and imported to Blaze Advisor via the XSLT stylesheet. When applied to 73,841 outpatients' insurance claims data, the review result was the same as that of the legacy system., Conclusion: We have demonstrated that ArdenML can replace a compiler for transforming MLMs into commercial rule engine format. While the proposed XSLT stylesheet requires refinement for general use, we anticipate that the development of further XSLT stylesheets will support various rule engines., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Background: Pediatric guidelines based care is often overlooked because of the constraints of a typical office visit and the sheer number of guidelines that may exist for a patient's visit. In response to this problem, in 2004 we developed a pediatric computer based clinical decision support system using Arden Syntax medical logic modules (MLM)., Methods: The Child Health Improvement through Computer Automation system (CHICA) screens patient families in the waiting room and alerts the physician in the exam room. Here we describe adaptation of Arden Syntax to support production and consumption of patient specific tailored documents for every clinical encounter in CHICA and describe the experiments that demonstrate the effectiveness of this system., Results: As of this writing CHICA has served over 44,000 patients at 7 pediatric clinics in our healthcare system in the last decade and its MLMs have been fired 6182,700 times in "produce" and 5334,021 times in "consume" mode. It has run continuously for over 10 years and has been used by 755 physicians, residents, fellows, nurse practitioners, nurses and clinical staff. There are 429 MLMs implemented in CHICA, using the Arden Syntax standard. Studies of CHICA's effectiveness include several published randomized controlled trials., Conclusions: Our results show that the Arden Syntax standard provided us with an effective way to represent pediatric guidelines for use in routine care. We only required minor modifications to the standard to support our clinical workflow. Additionally, Arden Syntax implementation in CHICA facilitated the study of many pediatric guidelines in real clinical environments., (Copyright © 2015 Elsevier B.V. All rights reserved.)