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Given the role opioid overprescribing has played in the current overdose crisis, reducing the supply of prescription opioids available for misuse has gained widespread support. Prescription monitoring programs (PMPs) have been identified as a tool for achieving this goal, but little is known about how to promote PMP use to prescribers. This paper describes the process of developing a health communication campaign to support the adoption of the Texas PMP. After formative research, message development and concept testing, a range of campaign concepts and messages were tested and final recommendations determined. The messages and lessons learned have utility beyond Texas.

BACKGROUND Many dermatologic cases are first evaluated by primary care physicians or nurse practitioners. OBJECTIVE This study aimed to evaluate an artificial intelligence (AI)-based tool that assists with interpreting dermatologic conditions. METHODS We developed an AI-based tool and conducted a randomized multi-reader, multi-case study (20 primary care physicians, 20 nurse practitioners, and 1047 retrospective teledermatology cases) to evaluate its utility. Cases were enriched and comprised 120 skin conditions. Readers were recruited to optimize for geographical diversity; the primary care physicians practiced across 12 states (2-32 years of experience, mean 11.3 years), and the nurse practitioners practiced across 9 states (2-34 years of experience, mean 13.1 years). To avoid memory effects from incomplete washout, each case was read once by each clinician either with or without AI assistance, with the assignment randomized. The primary analyses evaluated the top-1 agreement, defined as the agreement rate of the clinicians’ primary diagnosis with the reference diagnoses provided by a panel of dermatologists (per case: 3 dermatologists from a pool of 12, practicing across 8 states, with 5-13 years of experience, mean 7.2 years of experience). We additionally conducted subgroup analyses stratified by cases’ self-reported race and ethnicity and measured the performance spread: the maximum performance subtracted by the minimum across subgroups. RESULTS The AI’s standalone top-1 agreement was 63%, and AI assistance was significantly associated with higher agreement with reference diagnoses. For primary care physicians, the increase in diagnostic agreement was 10% (PP CONCLUSIONS AI assistance was associated with significantly improved diagnostic agreement with dermatologists. Across race and ethnicity subgroups, for both primary care physicians and nurse practitioners, the effect of AI assistance remained high at 8%-15%, and the performance spread was similar at 5%-7%.

All people in the United States deserve the same level of public health protection, making it crucial that every health department across the country has a core set of foundational capabilities. Current research indicates an annual cost of $32 per person to support the foundational public health capabilities needed to promote and protect health for everyone across the nation. Yet national investment in public health capabilities is currently about $19 per person, leaving a $13-per-person gap in annual spending. To “create the conditions in which people can be as healthy as possible” and to protect national security, this gap must be filled. The Public Health Leadership Forum convened national experts in the public health, public policy, and other partner sectors to develop options for long-term, sustainable financing. The group aligned around core principles and criteria necessary to establish a sustainable financing structure. Informed by the work of the expert panel, the authors recommend a Public Health Infrastructure Fund for state, territorial, local, and tribal governmental public health, that would provide $4.5 billion of new, permanent resources needed to fully support core public health foundational capabilities.

Background Many dermatologic cases are first evaluated by primary care physicians or nurse practitioners. Objective This study aimed to evaluate an artificial intelligence (AI)-based tool that assists with interpreting dermatologic conditions. Methods We developed an AI-based tool and conducted a randomized multi-reader, multi-case study (20 primary care physicians, 20 nurse practitioners, and 1047 retrospective teledermatology cases) to evaluate its utility. Cases were enriched and comprised 120 skin conditions. Readers were recruited to optimize for geographical diversity; the primary care physicians practiced across 12 states (2-32 years of experience, mean 11.3 years), and the nurse practitioners practiced across 9 states (2-34 years of experience, mean 13.1 years). To avoid memory effects from incomplete washout, each case was read once by each clinician either with or without AI assistance, with the assignment randomized. The primary analyses evaluated the top-1 agreement, defined as the agreement rate of the clinicians’ primary diagnosis with the reference diagnoses provided by a panel of dermatologists (per case: 3 dermatologists from a pool of 12, practicing across 8 states, with 5-13 years of experience, mean 7.2 years of experience). We additionally conducted subgroup analyses stratified by cases’ self-reported race and ethnicity and measured the performance spread: the maximum performance subtracted by the minimum across subgroups. Results The AI’s standalone top-1 agreement was 63%, and AI assistance was significantly associated with higher agreement with reference diagnoses. For primary care physicians, the increase in diagnostic agreement was 10% (P Conclusions AI assistance was associated with significantly improved diagnostic agreement with dermatologists. Across race and ethnicity subgroups, for both primary care physicians and nurse practitioners, the effect of AI assistance remained high at 8%-15%, and the performance spread was similar at 5%-7%. Acknowledgments This work was funded by Google LLC. Conflicts of Interest AJ, DW, VG, YG, GOM, JH, RS, CE, KN, KBD, GSC, LP, DRW, RCD, DC, Yun Liu, PB, and Yuan Liu are/were employees at Google and own Alphabet stocks.

Ensuring the conditions for all people to be healthy, though always the core mission of public health, has evolved in approaches in response to the changing epidemiology and challenges. In the Public Health 3.0 era, multisectorial efforts are essential in addressing not only infectious or noncommunicable diseases but also upstream social determinants of health. In this article, we argue that actionable, geographically granular, and timely intelligence is an essential infrastructure for the protection of our health today. Even though local and state efforts are key, there are substantial federal roles in accelerating data access, connecting existing data systems, providing guidance, incentivizing nonproprietary analytic tools, and coordinating measures that matter most.

Chapters 3 examines the challenges of addressing broad health issues which face communities now. It argues that these are effectively achieved only through partnerships across sectors, which create conditions in which everyone can be healthy. The underpinning for this approach lies in recognising that the most crucial factors influencing the public's health are not in the health sector per se, but are rather a result of the influence of a multitude of factors at family, community, city, state, and federal levels. These include social and economic factors (such as poverty, racism, and other forms of discrimination), social isolation, and policies governing the the social determinants of health. The sectors that influence these factors, the chapter states, include housing, education, transportation, economic development, city and county planning, and public safety. The chapter goes on to express how these partnerships can be formed and what they can do.

In this issue of the Annals of Family Medicine , Dr Johansen adds to our understanding that despite efforts to control health care costs over the past 2 decades, we are quickly approaching a reality in which health care spending subsumes one-fifth of our economy, which is well above our

In April 2004, President Bush signed Executive Order 13335, which called for the establishment of the Office of the National Coordinator for Health Information Technology (ONC) within the US Department of Health and Human Services. The President charged ONC with the critical responsibility of ensuring that every American had access to his or her electronic health information and establishing connectivity of health information technology.

Public health is what we do together as a society to ensure the conditions in which everyone can be healthy. Although many sectors play key roles, governmental public health is an essential component. Recent stressors on public health are driving many local governments to pioneer a new Public Health 3.0 model in which leaders serve as Chief Health Strategists, partnering across multiple sectors and leveraging data and resources to address social, environmental, and economic conditions that affect health and health equity. In 2016, the US Department of Health and Human Services launched the Public Health 3.0 initiative and hosted listening sessions across the country. Local leaders and community members shared successes and provided insight on actions that would ensure a more supportive policy and resource environment to spread and scale this model. This article summarizes the key findings from those listening sessions and recommendations to achieve Public Health 3.0.

Eight years ago, the HITECH Act launched an ambitious effort to modernize the U.S. health IT infrastructure. But the culture surrounding access to and sharing of information still needs to change to promote the seamless and secure flow of electronic information.

During a disaster or prolonged power outage, individuals who use electricity-dependent medical equipment are often unable to operate it and seek care in acute care settings or local shelters. Public health officials often report that they do not have proactive and systematic ways to rapidly identify and assist these individuals. In June 2013, we piloted a first-in-the-nation emergency preparedness drill in which we used Medicare claims data to identify individuals with electricity-dependent durable medical equipment during a disaster and securely disclosed it to a local health department. We found that Medicare claims data were 93% accurate in identifying individuals using a home oxygen concentrator or ventilator. The drill findings suggest that claims data can be useful in improving preparedness and response for electricity-dependent populations.

The article explores how behavioral health fits into supporting local public health in the U.S. Topics discussed include behavioral health challenges facing the U.S., including opioid and substance use disorder epidemics, the need to modernize public health and a proposal known as Public Health 3.0, which will be further explored in the issue.

The requisite capacities and capabilities of the public health practitioner of the future are being driven by multiple forces of change, including public health agency accreditation, climate change, health in all policies, social media and informatics, demographic transitions, globalized travel, and the repercussions of the Affordable Care Act. We describe five critical capacities and capabilities that public health practitioners can build on to successfully prepare for and respond to these forces of change: systems thinking and systems methods, communication capacities, an entrepreneurial orientation, transformational ethics, and policy analysis and response. Equipping the public health practitioner with the requisite capabilities and capacities will require new content and methods for those in public health academia, as well as a recommitment to lifelong learning on the part of the practitioner, within an increasingly uncertain and polarized political environment.

In 2016, the U.S. Department of Health and Human Services Office of the Assistant Secretary for Health launched the Public Health 3.0 initiative to define a framework for the future of public health. Regional Public Health Training Centers are at the forefront of testing new pedagogical approaches that incorporate Public Health 3.0 and social determinants of health principles.

Cognitive impairment is common among persons with chronic kidney disease, but the extent to which nontraditional vascular risk factors mediate this association is unclear.We conducted cross-sectional analyses of baseline data collected from adults with chronic kidney disease participating in the Chronic Renal Insufficiency Cohort study. Cognitive impairment was defined as a Modified Mini-Mental State Exam score1 SD below the mean score.Among 3591 participants, the mean age was 58.2±11.0 years, and the mean estimated GFR (eGFR) was 43.4±13.5 ml/min per 1.73 m2. Cognitive impairment was present in 13%. After adjustment for demographic characteristics, prevalent vascular disease (stroke, coronary artery disease, and peripheral arterial disease) and traditional vascular risk factors (diabetes, hypertension, smoking, and elevated cholesterol), an eGFR30 ml/min per 1.73 m2 was associated with a 47% increased odds of cognitive impairment (odds ratio 1.47, 95% confidence interval 1.05, 2.05) relative to those with an eGFR 45 to 59 ml/min per 1.73 m2. This association was attenuated and no longer significant after adjustment for hemoglobin concentration. While other nontraditional vascular risk factors including C-reactive protein, homocysteine, serum albumin, and albuminuria were correlated with cognitive impairment in unadjusted analyses, they were not significantly associated with cognitive impairment after adjustment for eGFR and other confounders.The prevalence of cognitive impairment was higher among those with lower eGFR, independent of traditional vascular risk factors. This association may be explained in part by anemia.

After Hurricane Katrina devastated New Orleans in 2005, the United States responded by revamping its approach to preparedness, hardening the medical infrastructure, leveraging technology, and build...

OBJECTIVES: To investigate cognitive impairment in older, ethnically diverse individuals with a broad range of kidney function, to evaluate a spectrum of cognitive domains, and to determine whether the relationship between chronic kidney disease (CKD) and cognitive function is independent of demographic and clinical factors. DESIGN: Cross-sectional. SETTING: Chronic Renal Insufficiency Cohort Study. PARTICIPANTS: Eight hundred twenty-five adults aged 55 and older with CKD. MEASUREMENTS: Estimated glomerular filtration rate (eGFR, mL/min per 1.73 m2) was estimated using the four-variable Modification of Diet in Renal Disease equation. Cognitive scores on six cognitive tests were compared across eGFR strata using linear regression; multivariable logistic regression was used to examine level of CKD and clinically significant cognitive impairment (score ≤1 standard deviations from the mean). RESULTS: Mean age of the participants was 64.9, 50.4% were male, and 44.5% were black. After multivariable adjustment, participants with lower eGFR had lower cognitive scores on most cognitive domains (P

BACKGROUND: The field of hospital medicine is growing rapidly in academic medical centers. However, few organizations have explicitly considered the opportunities for and barriers to hospital medicine's development as an academic field in internal medicine. OBJECTIVE: The objective was to develop consensus around key areas limiting or facilitating hospital medicine's development as an academic discipline. DESIGN: The design was a consensus format conference of key stakeholders in academic hospital medicine. RESULTS: The consensus group identified several issues impeding the development of academic hospital medicine as a recognized entity in academic settings, including extraordinarily rapid growth, increasingly preponderant nonteaching roles, and demands to perform nonclinical duties (such as quality improvement) not generally viewed as academic pursuits. The consensus group developed recommendations for addressing these concerns, specifically: 1) characterizing the optimal job description for an academic hospitalist, 2) developing better local and at-a-distance opportunities for training academic hospitalists in key aspects of early career success, and 3) advocating for the development of fellows and junior faculty researchers in hospital medicine. SUMMARY: Fostering academic hospital medicine will help address these issues more effectively and will help the field while also attracting the next generation of generalists needed to care for an increasingly complex inpatient population. Journal of Hospital Medicine 2009;4:240–246. © 2009 Society of Hospital Medicine.

The Hurricane Coping Self-Efficacy (HCSE) measure is a validated tool for assessing self-efficacy appraisals after hurricanes. Data were collected 6 months after Hurricane Katrina from 1542 employed residents of New Orleans, and 181 participants randomly selected to complete a repeat survey to confirm the psychometric properties of the HCSE measure. Overall, coping self-efficacy was greater among men, the most educated and those with the highest income. Confirmatory factor analyses indicated a relatively good fit of the HCSE items into a single construct, with Bentler's comparative fit and McDonald's centrality index scores of 0.92 and 0.87, respectively. The repeatability of scores was high (Pearson's correlation = 0.70). Additionally, HCSE scores were highly correlated with validated scales of perceived stress and posttraumatic stress symptoms, and significantly lower scores were observed among participants who sought counseling after the storm. The HCSE measure exhibited excellent internal consistency, external validity and repeatability after Hurricane Katrina.

Poor medication adherence may contribute to low hypertension control rates. In 2005, 295 hypertensive patients who reported taking antihypertensive medication were administered a telephone questionnaire including an 8-item scale assessing medication adherence. Overall, 35.6%, 36.0%, and 28.4% of patients were determined to have good, medium, and poor medication adherence, respectively. After multivariable adjustment, adults younger than 50 years and 51 to 60 years were 1.39 (95% confidence interval [CI], 0.56-3.42) and 1.53 (95% CI, 0.64-3.66), respectively, times more likely to be less adherent when compared with their counterparts who were older than 60 years. Black adults and men were 4.30 (95% CI, 1.06-17.5) and 2.45 (95% CI, 1.04-5.78) times more likely to be less adherent, respectively. Additionally, caring for dependents, an initial diagnosis of hypertension within 10 years, being uncomfortable about asking the doctor questions, and wanting to spend more time with the doctor if possible were associated with poor medication adherence. The current study identified a set of risk factors for poor antihypertensive medication adherence in the urban setting.

Background: Multi-item health status measures can be lengthy, expensive, and burdensome to collect. Single-item measures may be an alternative. We compared measurement properties of two single-item, general self-rated health (GSRH) questions to assess how well they captured information in a validated, multi-item instrument. Methods: We administered a general health survey (SF-12V) that included “standard” and “comparative” forms of a GSRH. We repeated the survey two weeks later to the same 75 medically stable outpatients to test for GSRH reproducibility, reliability, and validity using SF-12V Physical Functioning and Emotional Health subscales as a reference. Results: At each survey administration, the two GSRH questions demonstrated good alternate forms reliability (first administration: r=0.74, p

References to New Orleans as “the city that care forgot” first appear as far back as the 19th century. Although this reference has pointed, generally, to the high levels of poverty, we submit that forgotten “care” may refer to inadequate preventative and ambulatory health care for its residents. As the most recent US census and health statistics data indicate, this epithet remained apt through the city’s mandatory evacuation in anticipation of Hurricane Katrina making landfall last month. Twenty-eight percent of residents in New Orleans lived below the poverty line (43% of children under the age of 5 years). Health statistics reported by the Centers for Disease Control and Prevention estimated that 60% of adults in Louisiana were overweight, 25% had diagnosed hypertension, 31% had diagnosed high cholesterol, 8% had diagnosed diabetes, and 85% of residents did not participate in physical activity on a regular basis. Louisiana placed 50th in overall health (i.e., the absolute least healthy state), a precarious ranking it has held for 14 of the previous 15 years. The devastation that Hurricane Katrina and its aftermath wrought on the city of New Orleans has been described in vivid detail throughout the world’s press. We relate the salient facts here in brief. On August 29, 2005, Hurricane Katrina slammed the Gulf coast of the United States with sustained winds of 165 miles per hour. On August 30th, 2005, the levees protecting New Orleans from Lake Ponchartrain failed, resulting in widespread flooding in 80% of the city. During the days that followed, the plight of New Orleans’ poor was played out repeatedly on the international news. Evacuation plans for the poor and infirm were not well planned, executed, or communicated. In the nightmarish situation that followed the actual storms, tens of thousands were stranded on highways and at “refuge” stations waiting to be taken away from the heat and squalor. Many of these people were elderly and ill and had not been able to evacuate. Before Hurricane Katrina, the Medical Center of Louisiana at New Orleans (also known as Charity Hospital) served as the health care safety net for many of these people. Opened in 1736, it was the oldest continually operating hospital in the United States and had remained a crucial source of healthcare in the “city that care

Background Reliable approaches for measuring antihypertensive medication compliance in the outpatient setting are not readily available. The objective of the current study was to determine the reliability of the Hill-Bone Compliance Scale among elderly hypertensive patients. Methods We conducted a cross-sectional survey of community-dwelling patients attending the hypertension section of the Internal Medicine Clinic in a large multispecialty group practice. Participants (n = 239) completed a self-administered questionnaire consisting of demographic questions and the Hill-Bone Compliance to High Blood Pressure Therapy Scale, which includes a nine-item medication compliance subscale. Results The mean age of respondents was 69 years; 51% of patients were men, 73% were white, 86% had at least a high school education, and 61% were married. The Cronbach alpha was 0.68 for the medication compliance subscale. All nine items of the medication compliance subscale maintained higher correlations with their own subscale total than with the salt intake and appointment keeping subscale totals. After adjusting for other demographic variables, the odds ratio (95% confidence interval) of perfect medication compliance as reported on the medication compliance subscale was 1.71 (0.95–3.07) for participants 65 years of age and older versus those younger than 65 years of age, 2.53 (1.37–4.66) for whites versus non-whites, 1.27 (0.73–2.20) for males versus females, 1.30 (0.73–2.29) for married versus unmarried participants, and 1.63 (0.74–3.62) for those with at least a high school education versus those with less education. Conclusion The medication compliance subscale of the Hill-Bone Compliance Scale appears reliable and may be a useful tool for detecting noncompliant patients in outpatient settings.

This article is a retrospective case-control study of patients from a Veteran’s Affairs Medical Center and an urban public hospital. Patients (53) older than 55 at the time of their HIV diagnosis were age- and gender-matched to 106 HIV-negative controls. Potential predictors of HIV-infection were abstracted from the medical records. HIV-positive patients were more likely to have a history of sexually transmitted diseases, have Hepatitis B+, and have significant differences in their mean globulin, serum sodium, albumin, and hemoglobin levels. The mean albumin to globulin ratio was also statistically, significantly different between the HIV-positive patients and the controls. These data suggest that for patients older than 55, certain medical history parameters may be useful in predicting risk of being HIV-positive. An albumin to globulin ratio < 1.0, especially when combined with a history of alcohol abuse or prior sexually transmitted disease, should prompt all physicians to screen their older patients for HIV.

Objective We compared single- and multi-item measures of general self-rated health (GSRH) to predict mortality and clinical events a large population of veteran patients.

Background: Environmental factors may contribute to the increasing prevalence of obesity, especially in black and low-income populations. In this paper, the geographic distribution of fast food restaurants is examined relative to neighborhood sociodemographics. Methods: Using geographic information system software, all fast-food restaurants within the city limits of New Orleans, Louisiana, in 2001 were mapped. Buffers around census tracts were generated to simulate 1-mile and 0.5-mile “shopping areas” around and including each tract, and fast food restaurant density (number of restaurants per square mile) was calculated for each area. Using multiple regression, the geographic association between fast food restaurant density and black and low-income neighborhoods was assessed, while controlling for environmental confounders that might also influence the placement of restaurants (commercial activity, presence of major highways, and median home values). Results: In 156 census tracts, a total of 155 fast food restaurants were identified. In the regression analysis that included the environmental confounders, fast-food restaurant density in shopping areas with 1-mile buffers was independently correlated with median household income and percent of black residents in the census tract. Similar results were found for shopping areas with 0.5-mile buffers. Predominantly black neighborhoods have 2.4 fast-food restaurants per square mile compared to 1.5 restaurants in predominantly white neighborhoods. Conclusions: The link between fast food restaurants and black and low-income neighborhoods may contribute to the understanding of environmental causes of the obesity epidemic in these populations.

While just 10 years ago the health system largely relied on paper, today nearly all hospitals and three-fourths of office-based physicians are using certified electronic health records (EHRs), in part, as a result of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009.1 Moreover, thanks to the Affordable Care Act, more than 90% of Americans now have health insurance, meaning we now have the opportunity to have a clinical record of our care experience that can support longitudinal follow-up and improved population-level surveillance.2 Looking forward, we can clearly envision a health care landscape where data are abundant and flowing and used to guide care delivery decisions—a learning health system described in our Nationwide Interoperability Roadmap.3

The authors reflect on public health in the U.S. and the need to upgrade it. They state the U.S. ranks 27th in the world in life expectancy despite spending almost three trillion dollars annually in health care, while life expectancy for the poor is declining. They describe what they call Public Health 1.0 and 2.0, and mention how the Affordable Care Act improved health care access for everyone and catalyzed the move toward value-based payments. They reflect on components for Public Health 3.0

Objective. Despite the important inXuence of ambulatory appointment revisit intervals (RVI) on access to care, physicians receive no formal training in this area and research indicates that there is signiWcant practice variation. Our objective was to examine whether predictors of RVI assignment that we had assessed using vignettes were also signiWcant in the actual patient care setting. Data sources and study design. A cross-sectional survey of 59 internal medicine residents collected at the end of ofWce visits for patients with hypertension or diabetes. Two hundred and twenty-eight patients seen in 1997 for continuity care in two academic clinics in New Orleans, Louisiana. Data collection. The main outcome was RVI in weeks. We assessed the relationship between physician, visit, and patient-level covariates, and RVI assignment in univariate and multivariate analyses using hierarchical linear models. Principal findings. The mean RVI was 12.4 weeks (range 1–42 weeks) and was similar for patients with diabetes and hypertension. The Wnal model accounted for 35.7% of the variance in RVI assignment and included: perceptions of the patient’s systolic blood pressure, disease stability, and compliance; comorbidity, physician age, sex, and identity; and changing therapy for the primary diagnosis. The identity of the physician was the largest contributor to the variance, accounting for 14.7%. Conclusions. Intrinsic characteristics of physicians and their subjective interpretations of their patients’ disease stability are the most important determinants of ambulatory RVI assignment. Intervening to reduce this variation in practice is challenging because limited research is currently available on the optimum RVI for patients with chronic illnesses such as diabetes and hypertension.

Background To analyze whether internists are suited for their role in treating the growing numbers of obese patients, we surveyed residents about their knowledge and attitudes regarding obesity. Previous assessments have not analyzed familiarity with obesity measurement tools or the correlation between knowledge and attitudes. Methods We administered a survey to 87 internal medicine residents in two urban, university-based residency programs. Results Almost all respondents understood the medical consequences of obesity, but 60% did not know the minimum BMI for diagnosing obesity, 69% did not recognize waist circumference as a reasonable measure of obesity, and 39% incorrectly reported their own BMI. Although nearly all respondents agreed that treating obesity was important, only 30% reported treatment success. Forty-four percent felt qualified to treat obese patients, and 31% reported treatment to be futile. Knowledge and attitudes were not correlated. Rasch analysis of knowledge and attitude subscales showed satisfactory model fit and item reliability of at least 0.96. Conclusions Despite solid knowledge of the comorbid conditions associated with obesity, residents have a poor grasp of the tools necessary to identify obesity. They also have negative opinions about their skills for treating obese patients. Residency training not only must improve knowledge of obesity measurement tools but also must address physicians’ negative attitudes toward obesity treatment.

Over the past decade, through both deliberate policy and programmatic action, the nation has made significant progress in the adoption and use of health information technology (IT). The pace of this progress accelerated dramatically beginning in 2009 with the passage and implementation of the Health Information Technology for Economic and Clinical Health (HITECH) Act. Prior to that time, though there were certainly aspirational programs and communities, the adoption and use of health IT sharing among and between key stakeholders, including clinicians, hospitals, consumers, and others, was only just beginning and was moving slowly. Since then, we have seen significant increases in the adoption and use of certified technology among eligible professionals and hospitals. Three-quarters of eligible professionals and nine in ten eligible hospitals have received incentive payments from the Medicare and Medicaid EHR incentive programs. This progress is the result of public-private partnerships supported through a set of grant programs such as the Regional Extension Centers and the Electronic Health Care Record Incentive Programs. HITECH has also supported advancement in the exchange of health information. More than six in ten hospitals have exchanged patient health information electronically with providers outside their organization, a 51 % increase since 2008. Seven in ten health care providers use an EHR to e-prescribe on the Surescripts network, and more than half of new and renewed prescriptions are sent electronically.1 The progress to date has laid a strong foundation, but there is much work that remains in order to achieve our shared vision of a world where patients and their care providers can access appropriate health information in an electronic format, when and how they need it, to save lives, make care convenient and well-coordinated, and allow for improvements in overall health. To build on this strong foundation, we are working with all stakeholders to develop a shared Interoperability Roadmap that charts a path to achieve progress in three, six, and ten years. We have structured our work along five critical building blocks for a nationwide interoperable health IT infrastructure: Core technical standards and functions Certification to support adoption and optimization of health IT products and services Privacy and security protections for health information Supportive business, clinical, and regulatory environments Rules of engagement and governance Individuals and their caregivers will have a vital role to play and interest in advancing interoperability. The amount of information available to consumers today is increasing, due in part to the meaningful use program and the Blue Button Initiative. As more health and health care information is converted to electronic formats and is available for exchange among providers and patients, it will be important to develop a method for consistently representing, managing, and communicating privacy preferences and consent across the ecosystem. The thoughtful work outlined in this JGIM supplemental is an example of one piloted approach for representing, managing, and communicating privacy preferences and consent. This work was funded through a cooperative agreement made possible by HITECH and was issued by the Office of the National Coordinator for Health Information Technology (ONC) to Indiana Health Information Technology, Inc., the Indiana University School of Medicine, and Regenstrief Institute, Inc. Caine et al. report on 30 patients with data stored in an EHR who were interviewed in order to gauge their current understanding of what is in their medical record, what methods they have to control access to their health information, privacy concerns around data sharing, and their desire for future data-sharing capabilities. Caine et al. used the findings from the patient interviews to develop six design principles suggested for use in creating patient-centered tools to enable patients to control access to their EHR data: 1) easy patient access to their EHR data, 2) reports of what is currently shared with whom, 3) granular, hierarchical control, 4) time-based controls, 5) contextual privacy controls, and 6) access notification. In Meslin et al., bioethical points to consider in constructing a patient-controlled EHR are analyzed. Leventhal et al. outline the outcomes of a pilot in a primary care clinic wherein patients were able to record their preferences and designate which of the health care providers in the clinic would be able view their electronic health records, and what data, if any, they wished to redact. Tierney et al. analyze the responses of providers participating in the primary care clinic pilot in which patients were given granular control over their EHR data. Schwartz et al. provide an analysis of the responses of patients participating in the primary care clinic pilot. In Caine and Tierney, opposing views are debated regarding the value and utility of increased patient control over their health information. The manuscripts in this supplement offer many useful insights into patients’ desire for control over how their health information is accessed and shared. These insights should be considered by policymakers, providers, and health IT system developers in the design and implementation of future policies and systems – particularly as we move to a world in which the person is at the center of their health care, their health outcomes, and their electronic health information. Patients are already managing many aspects of their lives digitally in other domains, and are increasingly expecting the same capability for their health information. Nearly seven in ten individuals believe online access to their health information is very or somewhat important.2 Moving forward, it is vital that we respond to this demand and include individuals as active participants in the health IT ecosystem. More work is necessary on the policy and standards front to further advance this effort and to ensure that people have the ability to appropriately express their consent preferences, and that providers and vendors implement these preferences in a clear and consistent manner. We look forward to working with our partners at the federal level, in the private sector, with the academic community, and with consumers in achieving these goals.

Mega-disasters the scale and scope of Hurricane Katrina have been exceedingly rare in the USA. Nonetheless, careful study of such disasters can provide lessons learned that can lend essential insights to guide planning for future events of any size.1 Such disasters can also expose previously under-recognized frailties in society that, like the under-built levees of New Orleans, readily buckle under stress. One such frailty exposed by the storm was the health care safety net. Katrina was in many ways the “perfect storm” not only because of her meteorological characteristics but because she struck a portion of the world with high prevalence of chronic conditions, high rates of uninsured, and a geographically and financially consolidated safety net system.2 At the heart of the devastated area was the Medical Center of Louisiana at New Orleans (formerly known as Charity Hospital), the primary source of first-contact and chronic disease care for hundreds of thousands of uninsured and underinsured persons in the Greater New Orleans area. Katrina’s devastating flood rendered this Center completely inoperable. This confluence of events left hundreds of thousands of vulnerable patients with chronic conditions in the most densely populated hurricane-affected areas suddenly with no access to care. In this issue of JGIM, the Hurricane Katrina Community Advisory Group present the findings of their telephone survey assessing the impact of Hurricane Katrina of survivors with chronic disease among a sample from New Orleans and other affected areas.3 In their large representative sample, one in five persons reported having cut back or terminated treatment for a major chronic illness after the hurricane. Characteristics independently associated with treatment disruption included age younger than 65, having fewer relatives within and beyond hurricane-affected areas, and suffering two or more geographic relocations by early 2006, roughly 4–6 months after the disaster. Insurance was not an independent predictor in multivariable analysis, but this variable may have been difficult to disentangle from age, given the role of Medicare. Their complementary listing of respondents’ self-reported reasons for treatment interruption highlighted limited access to physicians and medications, insurance/payment issues, and competing demands for patient’s time and attention. These factors are strikingly similar to those reported in research among Americans experiencing homelessness in the absence of major humanitarian disasters.4,5 Minimizing disruption to the care of persons with chronic disease requires weaving a health care safety net resilient to the stress of disasters and to the more personalized disasters such as job loss or loss of one’s home.6 The design of a resilient health care safety net should pivot on recognition that continuing care for patients with chronic illness and their associated complex needs requires sufficiently nuanced policies. We posit that a health care safety net, capable of caring for patients with chronic disease during routine times and disasters, must take account not one, but three types of “homes”, each interdependent and supporting the other. Health care policies to shore up the safety net should drive the development of a web-enabled “medical home”,4,5 a portable financing mechanism for their care, an “insurance home”, and sufficient social support and resources to allow for self-care and management sufficient to help them respond to life’s challenges, a “social home”.

Argues that destruction of the training environment by Katrina opened an opportunity for rapid innovation and improvement of the physician training environment for the internal medicine residency at Tulane School of Medicine.