# data[].attributes.attachment_link.readable_text
Skip to Main Content

It looks like you're using Internet Explorer 11 or older. This website works best with modern browsers such as the latest versions of Chrome, Firefox, Safari, and Edge. If you continue with this browser, you may see unexpected results.

Your browser is unsupported

We recommend using the latest version of IE11, Edge, Chrome, Firefox or Safari.

We have made revisions based on input from the previous survey. We ask that all users, whether you have already taken the survey or not, please take a moment to give us your feedback.

Background Vs. Foreground Questions

In the Evidence Based Medicine paradigm, questions can be categorized into two types to help you grow your knowledge and practice. By determining the type of question, it will guide you to the type of evidence to review for an answer.

1. Background questions concern general knowledge of a condition, disease, process, etc. These types of questions generally have only two parts:

A question root (who, what, when, where, how, why) and

a disorder, test, treatment, or another aspect of health care.

Often these questions can best be answered by using a health sciences textbook or consulting a clinical point-of-care tool like DynaMed or UpToDate.
Examples:

What is a first line treatment for heart failure?

When should children receive the HPV vaccine?

What gene mutation causes polycystic kidney disease?

2. Foreground questions are specific knowledge questions

that affect clinical decisions and

include a broad range of biological, psychological, and sociological issues.

Foreground questions are best suited to the PICO model as it captures the essential elements of your information need to help translate that question into a search query. To obtain answers, generally it requires a search of the primary medical literature in databases like PubMed or Embase.
Examples:

In adults with heart failure, would adding warfarin to standard therapy reduce thromboembolism?

Are patient education YouTube videos effective at changing the preferences of vaccine-hesitant parents?

Does taking tolvaptan in adult patients with autosomal dominant polycystic kidney disease improve renal function and pain within six months of initiation of the medication?

Foreground questions may be further categorized into a type of clinical question such as treatment/therapy, diagnosis, prognosis, or etiology/harm that will also help in seeking out appropriate evidence types to address your inquiry. See more about question types on the CLINICAL FILTERS page.

What is the PICO Model?

ThePICO Model is a format to help define your information need into a clinical question. By organizing a clinical question using PICO, the searcher can use the specific terms to aid in finding clinically relevant evidence in the literature. PubMed alone has over 34 million citations to search through so being able to reference a defined clinical question when reviewing title/abstracts will help filter the irrelevant materials out of the search results.

The PICO Model for Clinical Questions

P

Patient, Population, or P roblem

How would I describe a group of patients similar to mine?

Need to Refine your Search Further? Try these additional elements in the PICOTTS Model.

For more on searching by Type of Question, see CLINICAL FILTERS.

For more on searching by Study Design, see LEVELS OF EVIDENCE.

PICO: Developing the Answerable Clinical Question

This 10 minute lecture focuses on developing clinical questions and learning how the PICO format can aid our search for the best clinical evidence.

# data[].attributes.attachment_link.title
Subject and Course Guides: Evidence Based Medicine: Asking Clinical Questions

# data[].attributes.attachment_link.description
Skip to Main Content It looks like you're using Internet Explorer 11 or older. This website works best with modern browsers such as the latest versions of Chrome, Firefox, Safari, and Edge. If you continue with this browser, you may see unexpected results. We recommend using the latest version of IE11, Edge, Chrome, Firefox or Safari.

# data[].attributes.attachment_link.readable_text
Sign up now for notifications when this page is updated

Anthem Blue Cross Blue Shield announced that approximately 78.8 million former and current policyholders nationwide had personal information stolen in a cyberattack of the company's IT system. The California Department of Insurance has opened an investigation of the Anthem security breach and wants you to protect yourself if you think you may be affected.

According to Anthem, information obtained by scammers includes:

Names

Birth dates

Medical IDs/Social Security Numbers

Employment/Income Data

Street Addresses

Email Addresses

*Anthem does not believe credit card, banking information or medical information was stolen.

What happened?

On January 29, 2015, Anthem reports that it discovered the unauthorized access of consumer information including member names, member health identification numbers, dates of birth, Social Security numbers, addresses, telephone numbers, email addresses, employment information and income data. Anthem reports that not all members or former members had all of this information taken - for some members or former members only some of the information was taken. The breach was discovered by a database administrator who noticed his credentials were being used without his knowledge or consent. According to Anthem, the database access was immediately shut down and every Anthem employee was required to reset their passwords. Anthem currently has 37 million enrollees nationwide. Anthem reports that the data breach also includes past enrollees-potentially up to 80 million people could have information compromised.

Who was affected?

Current and past enrollees dating back to 2004, including independent Blue Cross and Blue Shield plans. In total, up to 78.8 million people, including minors under the age of 18, may have information compromised.

13.5 million records of Californians containing personal information were accessed by hackers in the Anthem cyberattack. Of all the states, the largest number of records stolen were from Anthem's California customers.

How do I know if my personal information as accessed?

Anthem has sent emails to millions of members who provided their email addresses and who had information in the database that was compromised. Anthem is sending mailed notifications through U.S. Postal Service.

In addition to the notices that Anthem is sending by U.S. Postal Service mail to the 78.8 million potentially breach-impacted members, Anthem is also sending email correspondence with the same information regarding the breach and how to protect themselves to policyholders who elected to receive email notifications from Anthem .

Consumers should still be cautious of electronic communications and be aware of phishing scam emails.

Anthem customers should not reply to or open attachments from any emails that include a "click here" link and should never provide sensitive information (i.e. Social Security Number or financial information) in response to emails or phone calls.

What is Anthem doing to protect my information?

Anthem notified the Federal Bureau of Investigation once the breach was discovered, and sent email notices to Anthem consumers for whom Anthem had email addresses. Anthem has retained a cybersecurity firm to evaluate the extent of the attack. Anthem has reported that it is working to determine exactly whose information was taken and what information was taken. Anthem will then notify all affected consumers by U.S. Postal Service mail. Consumers should be suspicious of any other form of correspondence that appears to be from Anthem about the loss of their personal information.

Anthem also reports that it will provide free credit monitoring and identify protection services to all who were affected. Consumers are able to sign up for these services and they will be free of charge for two years. Information on how to enroll is posted at anthemfacts.com.

Identity Repair Assistance: AllClear ID is able to assist Anthem customers whose information may have been breached with identity repair assistance. This service is automatically available with no enrollment required. If a problem arises, consumers should call the Anthem helpline and an investigator will work to recover financial losses, restore and repair credit to pre-theft status.

For greater protection, consumers should actively enroll in AllClear Pro services, which offer the following:

Credit monitoring: Alerts consumers when banks and creditors use their identity to open new credit accounts.

Child identity protection: For a child under 18 years old, AllClear ID ChildScan finds acts of fraud against children by searching data files for use of your child's information.

Identity theft insurance: A $1 million identity theft insurance policy.

This information is being mailed and/or emailed by Anthem to former and current customers, however, you do not have to wait for such notifications to enroll. Customers may enroll in these services by visiting anthemfacts.com and clicking on the AllClear ID link or by calling 877-263-7995. California Insurance Commissioner Dave Jones advises current and former Anthem customers who may have been victims of the breach to enroll immediately in the extra protection. He also advises parents enroll their children and remain vigilant in monitoring their credit even beyond those 24 months.

What is the California Department of Insurance doing?

Insurance Commissioner Dave Jones has directed the Department of Insurance to open an investigation of Anthem's data breach. Commissioner Jones has been in communication with Anthem officials regarding the steps Anthem is taking to respond to the breach. The Department will continue to monitor the situation and work to make sure that Anthem provides consumers with the resources they need to address negative impacts on credit or other financial consequences of the breach.

Commissioner Jones works with other state insurance regulators throughout the country, through the National Association of Insurance Commissioners (NAIC). Given the potential scope of the breach and the number of consumers impacted, the NAIC has announced a national, multi-state examination of the Anthem companies and anticipates all 56 states and territories will sign on to the examinations, which will be inclusive of all subsidiaries and affiliates of Anthem affected by the breach.

The California Department of Insurance is a lead state in the multi-state combined financial and market conduct examination. The financial and market conduct examinations will investigate all aspects of the data breach. A major component will include analyzing Anthem's information technology systems to determine what protections were in place and what actions could have been taken to minimize data losses.

What should I do now?

Make sure to closely monitor your accounts, credit score, bank, credit card and other financial information. Contact your bank or Credit Card Company if you notice suspicious activity on your account.

Enroll in the AllClear ID Pro services at anthemfacts.com and contact the California Department of Insurance if you need help or have questions.

Most importantly, you should continue to monitor the situation closely. Anthem has said it is not yet aware of any fraudulent activity against policyholders that has occurred as a result of the breach. However, as with any data breach, be on the lookout for suspicious solicitations or communications, including email "phishing" efforts to collect sensitive information, like user names, passwords and credit card information.

Until Anthem identifies specifically which of its current and former consumers were impacted, you won't know if your data and what data was taken. If you are a current or former Anthem customer, you should review the consumer alerts that Anthem has released and posted on its websites.

Beware of Scammers

Members who may have been impacted by the cyberattack against Anthem should be aware of scam email campaigns targeting current and former Anthem members. These scams, designed to capture personal information (known as "phishing") are designed to appear as if they are from Anthem and the emails include a "click here" link for credit monitoring. These emails are NOT from Anthem.

Do not click on any links sent to you in an email or via social media, as scammers will try to take advantage of the breach. Often they will send phishing emails that appear to be from your bank or Anthem offering to help.

Anthem is not calling members regarding the cyberattack and is not asking for credit card information or social security numbers over the phone. All impacted members will receive notice via mail which will advise them of the protections being offered to them as well as any next steps.

Resources

Anthem's Consumer Helpline: (877) 263-7995

Website with up-to-date information regarding the breach: www.anthemfacts.com

California Department of Insurance Consumer Hotline: (800) 927-4357 (HELP)

Make an online inquiry at www.insurance.ca.gov

# data[].attributes.attachment_link.title
Consumer information on Anthem Blue Cross data breach

# data[].attributes.attachment_link.description
Anthem Blue Cross Blue Shield announced that approximately 78.8 million former and current policyholders nationwide had personal information stolen in a cyberattack of the company's IT system. The California Department of Insurance has opened an investigation of the Anthem security breach and wants you to protect yourself if you think you may be affected.

# data[].attributes.attachment_link.readable_text
Free shipping on all orders. Buy now

Join the 76% of 23andMe Health customers surveyed who took healthy actions after reviewing their genetic health reports. Whether it's exercising more, eating healthier or simply getting more sleep, you can make healthier happen today.†
Shop now

If you want the most comprehensive ancestry breakdown on the market.

2500+ Geographic regions

Automatic Family Tree Builder

30+ Trait reports

DNA Relative Finder

Learn more

Buy now

If you want to get a more complete picture of your health with insights from your genetic data.

Everything in Ancestry Service, plus...

65+ health reports and features including:

Health Predisposition reports*

Wellness reports

Carrier Status reports*

Includes FDA-authorized reports

Family Health History Tree

Learn more

Buy now

If you want our Health + Ancestry Service plus access to new premium reports and features throughout the year.

Everything in Health + Ancestry, plus...

Instant access to exclusive reports and features, including:

Heart Health reports

Pharmacogenetics reports (how you process certain medications)**

Migraine report (Powered by 23andMe research)

Reports and features that are "Powered by 23andMe Research" are developed by 23andMe scientists using data and insights gathered from thousands of customers who have consented to participate in our research.

Skin Cancer (Basal and Squamous Cell Carcinomas) and Skin Cancer (Melanoma) reports (Powered by 23andMe research)

Reports and features that are "Powered by 23andMe Research" are developed by 23andMe scientists using data and insights gathered from thousands of customers who have consented to participate in our research.

Plus new reports and features as more discoveries are made

Valid payment method required at kit registration

First year membership included (renews at $69/yr)

Learn more

Join now

Hi, we're 23andMe.

We're all about real science, real data and genetic insights that can help make it easier for you to take action on your health.

Among Health customers surveyed:

76% reported
making healthier
choices

55% reported
eating a healthier
diet

51% reported
setting healthy
goals

45% reported
increasing exercise

Know your personal story, in a whole new way.
Learn more

Know what makes you, you. Explore your traits.
Learn more

Choose the service
that's right
for you.

Know that you are in control of your DNA.

Discovery should never come at the expense of privacy. Your data is encrypted, protected and under your control. You decide what you want to know and what you want to share.
Learn more

Know you're making a difference.

When you opt in to participate in our research, you join forces with millions of other people contributing to science. Your participation could help lead to discoveries that may one day make an impact on your own health, the health of your family and ultimately, people around the world. (Look at you go.)
Learn more

How accurate is 23andMe?

23andMe has rigorous standards that ensure high-quality results. Our team of scientists and medical experts use a robust process to develop genetic reports for our customers. Here are specific examples:

With one of the largest reference datasets in the world, 23andMe provides customers with one of the most detailed and accurate ancestry breakdowns on the market. Our algorithms make ancestry estimates based on probabilities and they're generally very accurate, but your results are not set in stone. We are always trying to improve and refine these estimates.

Our Genetic Health Risk*, Carrier Status*, Pharmacogenetics** reports meet FDA requirements. This means that each variant in those reports demonstrated >99% accuracy and reproducibility when tested under different laboratory conditions. This article provides additional information.

How does 23andMe DNA testing work?

After you provide a saliva sample, 23andMe uses genotyping to analyze your DNA. This means we look at specific locations in your genome that are known to differ between people. We then turn those results into personalized genetic reports on everything from ancestry composition to traits to genetic health risks. Note that genotyping is different from DNA sequencing, which looks at every letter in a particular stretch of DNA.

Who can use 23andMe?

Most adults who are able to provide saliva samples can use the 23andMe kit. However there are some considerations that can complicate the DNA accuracy. Check out our Terms of Service for more info on those cases.

How do I get my 23andMe reports and how long does it take?

To begin, visit www.23andme.com/start. Once you have successfully registered your DNA testing kit, provided a saliva sample and put the kit in the mail, you can use the return tracking link available on your profile homepage to track your kit's progress to the lab. Once your sample reaches the lab, it is typically processed within a few weeks, with results then delivered to your secure online account.

Do 23andMe DNA test kits expire?

We encourage customers to provide their sample before the "Collect saliva by" date on the side of the collection tube. If your sample collection kit is lost or damaged, or if it has expired, please contact customer care to assist you with getting a replacement kit.

Why should I choose 23andMe?

There are many benefits of DNA testing, including finding relatives, learning whether you have genetic variants you could pass onto your children, and receiving personalized insights into your health and ancestry. 23andMe Health + Ancestry Service offers 150+ DNA reports that do just that. In addition to taking greater control of your own health and digging deeper into your ancestry, you can also opt in to participate in research that could help fuel scientific discoveries that benefit the larger community.

We're also committed to providing you with a safe place where you can learn about your DNA knowing your privacy is protected. 23andMe has sold 12+ million kits, and with each and every one of those, privacy has been our number one priority. You may learn more about our commitment to privacy here.

Stay in the know.

Keep up-to-date with new discoveries and exclusive promotions on our DNA testing kits and services.

*The 23andMe PGS test includes health predisposition and carrier status reports. Health predisposition reports include both reports that meet FDA requirements for genetic health risks and reports which are based on 23andMe research and have not been reviewed by the FDA. The test uses qualitative genotyping to detect select clinically relevant variants in the genomic DNA of adults from saliva for the purpose of reporting and interpreting genetic health risks and reporting carrier status. It is not intended to diagnose any disease. Your ethnicity may affect the relevance of each report and how your genetic health risk results are interpreted. Each genetic health risk report describes if a person has variants associated with a higher risk of developing a disease, but does not describe a person's overall risk of developing the disease. The test is not intended to tell you anything about your current state of health, or to be used to make medical decisions, including whether or not you should take a medication, how much of a medication you should take, or determine any treatment. Our carrier status reports can be used to determine carrier status, but cannot determine if you have two copies of any genetic variant. These carrier reports are not intended to tell you anything about your risk for developing a disease in the future, the health of your fetus, or your newborn child's risk of developing a particular disease later in life. For certain conditions, we provide a single report that includes information on both carrier status and genetic health risk. Warnings & Limitations: The 23andMe PGS Genetic Health Risk Report for BRCA1/BRCA2 (Selected Variants) is indicated for reporting of the 185delAG and 5382insC variants in the BRCA1 gene and the 6174delT variant in the BRCA2 gene. The report describes if a woman is at increased risk of developing breast and ovarian cancer, and if a man is at increased risk of developing breast cancer or may be at increased risk of developing prostate cancer. The three variants included in this report are most common in people of Ashkenazi Jewish descent and do not represent the majority of BRCA1/BRCA2 variants in the general population. This report does not include variants in other genes linked to hereditary cancers and the absence of variants included in this report does not rule out the presence of other genetic variants that may impact cancer risk. The PGS test is not a substitute for visits to a healthcare professional for recommended screenings or appropriate follow-up. Results should be confirmed in a clinical setting before taking any medical action. For important information and limitations regarding each genetic health risk and carrier status report, visit 23andme.com/test-info/

**23andMe PGS Pharmacogenetics reports: The 23andMe test uses qualitative genotyping to detect 3 variants in the CYP2C19 gene, 2 variants in the DPYD gene and 1 variant in the SLCO1B1 gene in the genomic DNA of adults from saliva for the purpose of reporting and interpreting information about the processing of certain therapeutics to inform discussions with a healthcare professional. It does not describe if a person will or will not respond to a particular therapeutic. Our CYP2C19 Pharmacogenetics report provides certain information about variants associated with metabolism of some therapeutics and provides interpretive drug information regarding the potential effect of citalopram and clopidogrel therapy. Our SLCO1B1 Pharmacogenetics report provides certain information about variants associated with the processing of some therapeutics and provides interpretive drug information regarding the potential effect of simvastatin therapy. Our DPYD Pharmacogenetics report does not describe the association between detected variants and any specific therapeutic. Results for DPYD and certain CYP2C19 results should be confirmed by an independent genetic test prescribed by your own healthcare provider before taking any medical action. Warning: Test information should not be used to start, stop, or change any course of treatment and does not test for all possible variants that may affect metabolism or protein function. The PGS test is not a substitute for visits to a healthcare professional. Making changes to your current regimen can lead to harmful side effects or reduced intended benefits of your medication, therefore consult with your healthcare professional before taking any medical action. For important information and limitations regarding Pharmacogenetic reports, visit 23andme.com/test-info/pharmacogenetics/

# data[].attributes.attachment_link.title
DNA Genetic Testing For Health, Ancestry And More - 23andMe

# data[].attributes.attachment_link.description
23andMe offers DNA testing with the most comprehensive ancestry breakdown, personalized health insights and more.

# data[].attributes.body
Informatics Week 14

Legal and Ethical Isssues

Legal and regulatory matters when it comes to health informatics are no different than legal and regulatory matters in other fields or other areas.

There is a difference between law and ethics.

Ethical and legal issues often overlap.

Ethical considerations:

*attempts to determine what is good/meritorious and which behaviors are desirable/correct in accordance with higher principles.

Legal principles -derived from ethical ones but deal with the practical regulation of morality and behaviors and activities.

Laws- directly tell people how to behave under specific circumstances and prescribe remedies or punishments for individuals who do not comply with the law.

Examples of basic ethical principles that are universal:

*principle of autonomy:

all persons have the fundamental right to self-determination

(In regards to informatics, we need to preserve this right to self-determination. )

Principles of equality and justice:

*all persons are equal as persons and have a right to be treated accordingly.

Principle of beneficence: all persons have a duty to advance the good of others where the nature of this good is in keeping with the fundamental and ethically defensible values of the affected party.

(we all have to act in the way where it's beneficial to another person. We can't act in a way where someone might get hurt, knowingly get hurt, or purposely get hurt. )

The principle of non-malfeasance:

all persons have a duty to prevent harm to the other person insofar as it lies within the power to do so without hard to themselves.

The principle of impossibility:

all rights and duties hold subject to the condition that it's possible to meet them under circumstances that are obtained

Principld of integrity: whoever has an obligation has a duty to fill that absolute obligation to the best of her or his ability.

(making sure you do the right thing, even when no one's looking. And it's very, very important to be able to trust in people to do this.)

General principles of informatics ethics:

-(come from the International Medical Informatics Association)

*principle of information privacy and disposition:

All persons have a fundamental right to privacy and control over the collection, storage, access, use communication, manipulation, and disposition of data about themselves.

(have laws like HIPAA)

*principle of openness:

The collection, storage, access, use, communication, manipulation, disposition of personal data must be disclosed in an appropriate and timely fashion to the subject of these data.

*Principle of security:

data that has been legitimately collected about a person should be protected by all reasonable and appropriate measures against loss, degradation, unauthorized discussion, access, use, modification, or communication.

*Principle of access:

the subject of the electronic record has a right of access to that record and the right to correct the record with respect to accurateness, completeness, and relevance. (So patients do have the right to look at their records. They can make addendums to that record if there are incorrect information.)

*The principle of legitimate infringement:

the fundamental right of control over the collection, storage, access, use, manipulation, communication, and disposition of personal data is conditioned only by legitimate and appropriate and relevant data needs of a free and responsible democratic society and by the equal and competing rights of other persons.

*****

Consumer genetic testing is now available with companies, such as 23andMe.

For around $200, you can be tested for genetic health risks, ancestry, wellness, carrier status and traits, and predisposition to some illnesses.

*where you're from, where your ancestors are from, physical traits, the expression of the, how likely it is that it's expressed.

it introduces the general population into the field of genetics

Helpful especially if you don't know your family history at all (i.e.: somebody adopted)

Helps know about several chronic health conditions that may run in their family and  whether or not they're at a higher risk for those conditions

downsides to knowing genetic makeup:

*information is highly complex and sophisticated.

*to have a report that's handed with no explanation, no context, fails the consumer.

*one dimensional piece of information that could be extremely confusing or misleading and really not offer  much health information.

*could really be scary too.

*without the context of a genetic counselor really working through your family history and your health history, is just 1% of the picture.

*communication about what those findings mean is very important.

*****

23andMe and impacts of genetic testing:

How to approach a patient coming  with some results from some of the genetic testing:

*Discuss predisposition for certain conditions and screen for it

*But beyond that, you'd really have to involve a broader team.

23andMe sells the de-identified information to researchers:

*data go into sort of the big data pool to try to find answers to some questions about certain diseases

*having more and more samples is very powerful when you're collecting data.

# data[].attributes.body
Data visualization:

*term that describes effort to help people understand  significance of data by placing it in a visual context.

*Patterns, trends, and correlations that go undetected in text-based data can be exposed and recognized.

*It is storytelling with data.

key questions to consider when doing data visualization:

*What story is data trying to tell?

*What type of data do you want to explain?

*What chart type will display  data in the most efficient way? *Who is the audience?

exploratory versus explanatory analysis:

exploratory analysis-

*what is needed to understand the data.

*preliminary look at data to  figure out what it's trying to say

explanatory -

specific thing you want to explain, a specific story you'd like to tell.

after analysis in the exploratory phase, figure out if data answers the question

ultimate goal:

If you're trying to change health policy or practice in any way, that's where explanatory comes into play.

audience:

*important to know who you're communicating to.

*need to know who's going to be in the room

*who the stakeholders are, *what do you want them to know?

*What do you want them to do?

*What's the endpoint that you're trying to get to?

*how can you use the data to get your endpoint?

*know who stakeholders are and how they're related to your project.

*Some people in audience are the decision-makers

*Some people in audience are there to support.

*may want to narrow who you're inviting.

relationship:

*what kind of relationship do you have with the audience? *How are they going to perceive you?

*Do you need to build credibility?

*need to also come across as being the expert (looked at this data very intimately and know a lot about it)

Nancy Duarte

*has a company that is in the business of developing presentations of organizations

*made a model for different sections of the presentation process:

1*conceive the idea

2* visualize the idea

3*present the idea.

*question your data

***check data and make sure there's verification.

***There are sometimes errors in data entry and typos that were not caught in published data sets.

*clean the data

***make sure data in  database is consistent.

***ensure like terms if comparing two data sets

***pay attention to time frames (if have two things that were collected at different times, it might make a difference in  data analysis and visualization)

tools for visualization:

Microsoft Excel

Google Spreadsheets

Tableau

programming language (such as R)

types of charts:

*vertical bar chart

*waterfall chart- shows pattern

*horizontal bar chart

*area chart

*spider charts - helpful to see peak and ebb and flow patterns.

Choose the one that displays the information better and makes your point.

*using color is a technique to show patterns

*once you have looked for patterns and relationships, think about what conclusions you can draw from data

audience is  relying on you, as the expert, to come up with  these conclusions.

*allocate enough time to become an expert

*don't go down too many rabbit holes.

*****

Infographics

*a visual image (such as a charter diagram) to represent information or data.

"A good infographic is worth a thousand words. "

*fun and a quick way to learn about a topic without the tone of heavy reading.

*snippets of information

*usually visually pleasing.

set up data and organize it, and then figure out how to put it pictorially in this infographic.

*easy to read

*information gets presented in a very pleasing way.

tips for infographics:

*Choose an interesting title, *Include a diversity of resources and statistics. *Promote via social media websites and make it easy to share and embed the infographic.

*make it easy to share with people so they can forward it or like it.

*Make it easy for readers to engage

*avoid white background

*don't use too much text.

*if on social media, pay attention to how many hits it is getting.

Infographics are wildly popular now.

Pinterest has many infographics

huge marketing tool

also good in health care to get health information out there in a really easy and fun way.

important to put references at the bottom so people can search out more information.

American Public Health Association, APHA, has  a variety of infographics.

World Health Organization uses infographics for many of their messages on public health.

Explanatory data helps  crystallize the target data that you discover during the exploratory analysis.

Keep the message clean and to the point, provide what you found, and not your entire data analysis.

more tips on graphs and charts:

*remove clutter

*clean up the axis labels by labeling data directly and leveraging a consistent color.

*gather the graphs or charts you want in the infographic. *keep focused on the message. *consider using PowerPoint. (can make one big slide with all the information by changing the slide size)

*insert material: think of each item as a different graphic that you want to put in your infographic.

# data[].attributes.body
Data Analysis

definitions:

*machine learning- the area of computer science that aims to build systems and algorithms that learn from data.

*Data mining- the processing and modeling of large amounts of data to discover previously unknown patterns of relationships.

*Text mining -data mining to unstructured textual data, those free text fields.

*big data- large and ever increasing volumes of data that adhere to volume, velocity, variety, and veracity.

three levels of analytics:
1*descriptive- standard types of reporting describing current situations and problems.
2*Predictive -simulation and modeling to identify trends of actions taken
3*Prescriptive is optimizing clinical, financial, and other outcomes.

simple steps to basic analyzing data:
*first thing- ask a burning question/what are you trying to get answered with the data?

PICO format:
*Population
*Intervention
*Comparison
*Outcome
-used in evidence-based research.

*Find data that answers the burning question. there might be more than one data set.

*Do preliminary data visualization:

***scatterplot- graph it out to see what you have

***end with bar graph or a line graph in your visualizing data

*draw conclusions (look for patterns and trends)
***see the data as a picture, not individual numbers

*look at community wide counts for different data

*do a scatterplot chart in order to examine it:
***What is data saying
***What are the outliers?
***Is it telling you to refine?
***Do you have to drop out one level of detail from it or add something else in?

visualization tools
*Excel- can visualize data very easily, makes graphs
*Tableau -nice visualization tool, have a free trial or a public Tableau.

*next, clean the data:
***look for links, unique identifiers.
***visualize data in detail using tools and methods, and methodologies to come up with the best-looking types of visualizations
***draw conclusions/synthesize what you found.

*explain challenges process of answering burning question

*disseminating- data was turned into knowledge, became an expert at subject,
made information connect, it's important to spread the word/share the data and use the knowledge

***********

Storytelling

Storytelling- term that is often used in marketing
*communication tool
*nurse leaders can use storytelling to communicate and make a case to non-nurses.
*Data is powerful, harness it to tell a story
*Give insights of what was discovered when looked at the data.
*Data in conjunction with story is memorable.
*always want audience to know more.
*Tell story enthusiastically
*add a recommendation

# data[].attributes.body
Driving forces for privacy:

Health Insurance Portability and Accountability Act:

*the driving force for informatics dealing with clinical data

*The compliance deadline was set fully for 2006

*provides privacy and security measures in health care

*mandates to de-indentify data by removing 18 identifiers:

***date of birth

***address

***phone numbers

***identification

American Recovery and Reinvestment Act:

*added more rules

High Tech Act: strengthened rules

*National Provider Identifier- occurred in 2009

HIPAA rules:

*have safeguards in place to ensure data is not compromised and that it is only used for the intended purposes.

*should not impede the treatment of patients

*It covers health plans, which are health insurers, health care providers, health care clearinghouses.

*Not required and not covered in this act:

***insurance companies

***employers

***schools

***school districts

=have their own privacy law called FERPA

*many law enforcement agencies not covered by HIPPA

Security:

three A's:

*authentication

*authorization

+accountability

breaches:

Health care data can be worth $25 to $250 on the black market.

*It's more valuable than credit card data.

*Social Security numbers can be used for identity theft

*health care information can be used for submitting false claims, buying expensive medical equipment, such as oxygen, and selling on the black market, and getting health care under someone's else's identity.

*security methods that help prevent this:
checking driver's license when at health care visit or taking picture of patient

*many organizations are starting to take pictures and put it with your health record so that when patient comes in they can identify theyre the person  they're caring for.

Breach in Anthem:

* 2015

*found internally a few years ago, and contained information like Social Security, financial data, lots of different information.

*Most companies have cyber insurance to help, have to hire separate public relations firms specializing in breaches in order to help them through the public relations disaster that it might cause.

*80 million records for current and former customers and employees, including their names, birthdays, Social Security numbers, street addresses, email addresses, and employment information were included, including income data.

*breaches are a serious issue today in informatics.

********

Patient engagement:

*combines patients' knowledge, skills, ability, and willingness to manage their own care.

patient engagement methods:
*patient portals
*OpenNotes.

patient portals:

*important tools.

*help patients understand why tests are being ordered or what's going on in their care, which can motivate patients to become more involved.

*great way of communication about health

*shows lab results and testing that needs to be done for communicating, when the next test needs to happen, where the follow-up needs to be, and if tests are normal or abnormal

*convenient because getting to follow-up visit can be a barrier.

*secure messaging through the patient portal

*patient has to be enrolled in the patient portal.

Future features of portals:

*ways for patients to do self-triage, software that patient puts in their symptoms and it guides them through a pathway. helps determine if problem is urgent an need to go to emergency department or whether they can wait to call their physician.

*helpful to keep people out of the emergency department when its not necessary

other benefits to patient portals:

*motivating tool for patients.

*patients have the ability to look at their health summaries on their own time and their own space

*helps patients take more ownership of their conditions such as diabetes control, because they see what their A1C has done over a period of time.

*patient Empowerment

*visualization for patients

OpenNotes

*international movement that allows patients to see what the provider is putting into their medical record. *international movement that is now becoming more widespread

*substance abuse or violence within a home setting.

*benefit of transparency and trust

*patient can look at every note provider writes

*health care is moving to collaborative engagement and recognizing the patient as a partner in health

*when someone's writing something about you, especially personal health information, emotional information, psychiatric, patient has the right to see that.

*seeing provider write down exactly what was discussed can be objective, doesn't have to be soft on the details and can be very real, (this is what we're dealing with, this is our plan, this is where we're starting from)

*practitioners should be writing good, solid, objective notes that you would want to share with the patient.

# data[].attributes.attachment_link.readable_text
When Pablo Garcia was admitted, he felt fine. Then the hospital made him very sick. Blame high-tech medicine.

The nurses and doctors summoned to the hospital room of 16-year-old Pablo Garcia early on the morning of July 27, 2013, knew something was terribly wrong. Just past midnight, Pablo had complained of numbness and tingling all over his body. Two hours later, the tingling had grown worse.

Although Pablo had a dangerous illness-a rare genetic disease called NEMO syndrome that leads to a lifetime of frequent infections and bowel inflammation-his admission to the University of California, San Francisco Medical Center's Benioff Children's Hospital had been for a routine colonoscopy, to evaluate a polyp and an area of intestinal narrowing.

At 9 o'clock that night, Pablo took all his evening medications, including steroids to tamp down his dysfunctional immune system and antibiotics to stave off infections. When he started complaining of the tingling, Brooke Levitt, his nurse for the night, wondered whether his symptoms had something to do with GoLYTELY, the nasty bowel-cleansing solution he had been gulping down all evening to prepare for the procedure. Or perhaps he was reacting to the antinausea pills he had taken to keep the GoLYTELY down.

Levitt's supervising nurse was stumped, too, so they summoned the chief resident in pediatrics, who was on call that night When the physician arrived in the room, he spoke to and examined the patient, who was anxious, mildly confused, and still complaining of being "numb all over." He opened Pablo's electronic medical record and searched the medication list for clues that might explain the unusual symptoms.

At first, he was perplexed. But then he noticed something that stopped him cold. Six hours earlier, Levitt had given the patient not one Septra pill-a tried-and-true antibiotic used principally for urinary and skin infections - but 38½ of them.

Levitt recalls that moment as the worst of her life. "Wait, look at this Septra dose," the resident said to her. "This is a huge dose. Oh my God, did you give this dose?"

"Oh my God," she said. "I did."

The doctor picked up the phone and called San Francisco's poison control center. No one at the center had ever heard of an accidental overdose this large-for Septra or any other antibiotic, for that matter-and nothing close had ever been reported in the medical literature. The toxicology expert there told the panicked clinicians that there wasn't much they could do other than monitor the patient closely.

As a precaution, the hospital's rapid response team was summoned to the room. Pablo's mother, Blanca, who had been with her younger son, hospitalized one floor up at UCSF for a severe skin infection (he, too, suffers from NEMO syndrome), began a vigil by Pablo's bedside. "I phoned my sister, and we prayed together," she later recalled.

At 5:32 a.m., Brooke Levitt heard a scream coming from Pablo's room. It was Blanca Garcia. A few seconds earlier, her son had sat bolt upright in bed, yelled out "Mom!" then flopped backward. Levitt sprinted to the room, and when she got there, Pablo's head was snapping back and forth, teeth clenched, back arched, extremities thrashing. He was having a grand mal seizure. Moments later, just as the Code Blue team arrived, the teenager stopped breathing.

"I thought, what if I killed him?" Levitt told me months later, wiping away tears. "If he had a seizure, I'm wondering if that's going to be the end of it. . . I'm trying to hold it together, but I'm in shock the whole time. I just felt immensely guilty."

The night that Pablo Garcia was given a 39-fold overdose of a routine antibiotic offers a cautionary tale that cannot be ignored.

To appreciate how one of the nation's best hospitals- US News & World Report regularly ranks UCSF among the top 10 - could give a patient a 39-fold overdose of a common antibiotic, one first needs to understand how medicines were ordered and administered in hospitals as recently as a few years ago, before the system went digital.

Pablo Garcia had been taking one double-strength Septra tablet twice a day at home to prevent his frequent skin infections. In the old paper-based medication ordering system, the admitting doctor would have written "Septra 1 ds bid" (using the Latin abbreviation for "twice a day") in the "Doctors' Orders" section of a paper chart, a stack of sheets contained within a plastic three-ring binder.

The physician would have turned a colored wheel on the side of the binder to green, signaling to the ward clerk that there was an order to be "taken off." The clerk would then have faxed the order sheet to the pharmacy, where a pharmacist would have read it, signified his approval by initialing the page, and handed the copy to a technician, who would have grabbed a big bottle of Septra pills from a shelf. The tech would then have poured out the pill, or perhaps a few days' worth of pills, and put them in a bag or cup, which would have then been delivered to the patient's floor by a runner or a pneumatic tube system.

Once the pills arrived on the floor, at the appropriate time the patient's nurse would have read the order (manually transcribed from the doctor's order sheet to the nurse's Medication Administration Record) and entered the teenager's room pushing a wheeled cart similar to the ones used by airline flight attendants. After opening the patient's drawer in the cart, the nurse would have removed the medication, and others due to be given at the same time, watched the patient take the pill, and placed her signature next to the time and dose on her record.

Believe it or not, I've shortened this description - time and motion studies have identified as many as 50 steps between the moment the doctor wrote the order and the moment the nurse finally administered the medication. But even in simplified form, you can see why the old system was hugely error-prone. A study from the pen-and-paper era showed that 1 in 15 hospitalized patients suffered from an adverse drug event, often due to medication errors. A 2010 study (using data collected during the pre-digital era) estimated the yearly cost of medication errors in U.S. hospitals at $21 billion.

Those of us who worked in this Rube Goldberg system - and witnessed the harms it caused - anxiously awaited the arrival of computers to plug its leaks. Computerized ordering would make a doctor's handwriting as irrelevant as scratches on a record album. Computerized decision support would alert the doctor or pharmacist that the patient was allergic to the medication being ordered, or that two medications might interact dangerously. A pharmacy robot could ensure that the right medication was pulled off the shelf, and that the dose was measured with a jeweler's precision. And a bar-coding system would render the final leg in this relay race flawless, since it would signal the nurse if she had grabbed the wrong medication or was in the wrong patient's room.

Of course, it was natural for doctors, nurses and pharmacists to expect that, once computers entered our complex, chaotic and often dangerous world, they would make things better. After all, in our off-duty lives we are so thoroughly used to taking out our iPhones, downloading an app, and off we go.

But we're learning that the magic of information technology, so familiar to us in the consumer world that it nearly seems "normal," is far more elusive in the world of medicine.

Though computers can and do improve patient safety in many ways, the case of Pablo Garcia vividly illustrates that, even in one of the world's best hospitals, filled with well-trained, careful and caring doctors, nurses and pharmacists, technology can cause breathtaking errors.

This one began when a young physician went to an electronic health record and set a process in motion that never could have happened in the age of paper.

At around noon on a cool July day in San Francisco, Jenny Lucca, a pediatrics resident at UCSF, began the process of admitting Pablo Garcia, whose rare genetic disease had led to bouts of gastrointestinal bleeding and abdominal pain. He needed further evaluation with an elective colonoscopy, and this was a scheduled admission to perform the test and act on its results.

After speaking to Pablo and his mother and examining the young patient, Lucca clicked into the physicians' orders section in the electronic health record. Pablo was on about 15 different medications. Lucca ordered his usual immunosuppressive pills, the liquid bowel-cleansing prep for the colonoscopy (the famously vile GoLYTELY) and his monthly infusion of immunoglobulins.

Then she came to the Septra, an antibiotic that the teenager had been taking for years to prevent recurrent skin and lung infections. The usual dose of Septra for all but the smallest children is one double-strength pill twice daily, and that is what Pablo was taking at home.

In the precomputer days, of course, Lucca would have written simply to continue the Septra, twice daily, on the physician's order sheet.

But UCSF Medical Center, where I work as a physician, had not relied on paper for years. It had been over a decade since doctors and nurses wrote their daily notes on paper, and all of the orders had been electronic for nearly two years. Lucca, as a young physician, had never experienced a medical profession built on a backbone of paper documentation. She was of a generation of digital natives, for whom the use of the computer was natural and expected. After arriving in San Francisco, Lucca took the required 10 hours of computer training, and UCSF's system, built by Epic of Verona, Wisconsin-the same one she had used in medical school - made the learning curve far less steep than it might have been.

The medical center installed its first hospital-wide computer system in 2000. We switched to Epic, the market leader, in 2012 after an unhappy decade with General Electric's problem-ridden EHR system. Our implementation of Epic, like all such implementations, had its share of hiccups. Some departments didn't send out bills for weeks, some medications and lab tests were overlooked, and a few patients fell off the hospital's radar screen for brief periods. Like new homeowners, the IT department had a "punch list" of hundreds of items to be fixed or modified, and they spent much of the first year after implementation methodically going through it, checking off items.

But now, on the date of Pablo Garcia's admission, 13 months after UCSF's Epic installation, the system was running smoothly. And there was good evidence that it was meeting its goals: doctors' and nurses' notes were now legible; thousands of medication errors had been intercepted by the bar-coding system; and computerized checklists guided the clinicians through some key safety practices like identifying the correct surgical site before the first incision. Moreover, about 50,000 patients had signed up to access a new electronic portal called MyChart, which allowed them to receive results of lab tests and x-rays, schedule appointments, refill their medications, and e-mail their physicians. Although there were grumbles here and there, the general feeling was that the electronic health record was making patient care safer and better.

Yet a series of dangers lurked beneath the placid surface. Installing a system like Epic is not like installing an operating system on your laptop, where you just "Accept the Terms," reboot the machine and off you go. Instead, while the electronic health record provides the scaffolding, there are hundreds of decisions that each hospital needs to make, many of them related to electronic prescribing.

For example, should there be maximum dose limits set in the system, so that doses several times higher than the published maximum are grayed out? UCSF decided not to set such limits. The reasoning at the time was that, in a teaching hospital with lots of patients with rare diseases, many of them on research protocols, such "overdoses" would usually be okay. A system with hundreds of "hard stops" would lead to many angry phone calls from frustrated doctors to pharmacists, demanding that they override the block.

When it came to pediatric patients, a second set of decisions had to be made concerning weight-based dosing. Since pediatric patients can range from a preemie weighing a couple of pounds to a morbidly obese adolescent, many pediatric medications are dosed based on weight, usually expressed in milligrams (of a medication) per kilogram (of body weight)(mg/kg). The committee overseeing our Epic implementation decided to require weight-based dosing for all children under 40 kilograms (about 88 pounds).

Another choice involved the translation of weight-based doses into pills. What if the computer calculated that a dose should be 120 mg (based on the child's weight), but the only available pill was 100 mg? The decision: if the available medication was more than 5 percent off the calculated "correct" dose, then the pharmacist would contact the doctor to be sure she endorsed that conversion. After all, there might be cases in which a 10 or 20 percent disparity would be clinically meaningful and the doctor might rethink the order.

The weight-based dosing policy forced Lucca to order Pablo Garcia's medication in milligrams per kilogram, since the youngster weighed less than 40 kilograms (38.6 to be exact, or about 85 pounds). When she typed "Septra" into Epic's order entry module, she was prompted to select one of two dose choices, and she correctly chose the larger ("double-strength") one, which contains 5 mg/kg of trimethoprim, one of the two active ingredients in Septra.

Because Pablo weighed 38.6 kilogram, the computer multiplied this weight by the 5 mg/kg and determined that the dose should be 193 mg.

Of course, there is no 193 mg Septra pill; the nearest tablet size is the 160 mg double-strength Septra pill. The computer recommended that the dose be rounded to a single tablet (a 17 percent decrease from 193, well above the 5 percent threshold), and asked Lucca if she accepted this recommendation.

She clicked "Yes." In doing so, she believed she had ordered the one double-strength Septra tablet that Pablo had been taking at home, which was precisely what she had intended to do all along. All would have been well - had she been right. But she wasn't.

This is excerpted from The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age*, by Robert Wachter. McGraw-Hill, 2015. You can buy the book* here

Part 2: Beware of the Robot Pharmacist In tech-driven medicine, alerts are so common that doctors and pharmacists learn to ignore them - at the patient's risk.

Part 3: Why Clinicians Let Their Computers Make Mistakes We tend to trust our computers a lot. Perhaps too much, as one hospital nurse learned the hard way.

Part 4: Should Hospitals Be More Like Airplanes? "Alarm fatigue" at Pablo Garcia's hospital sent him into a medical crisis.

Illustrated by Lisk Feng

# data[].attributes.attachment_link.title
How Technology Led a Hospital To Give a Patient 38 Times His Dosage | Backchannel

# data[].attributes.attachment_link.description
When Pablo Garcia was admitted, he felt fine. Then the hospital made him very sick. Blame high-tech medicine. The nurses and doctors summoned to the hospital room of 16-year-old Pablo Garcia early on the morning of July 27, 2013, knew something was terribly wrong.

# data[].attributes.body
EHR

Dr. Robert Wachter -The Digital Doctor.

Wrote in his book about an error that happened that caused him to think about EHRs.

Error:

*16-year-old boy

*weighed 38.6 kilograms

*came in with chronic immunodeficiency disease, *admitted for colonoscopy as a workup for GI bleed.

*patient was on multiple home medications as a result of his chronic disease, including Septra Double Strength 160 mg BID, twice a day.

*At 1:09 PM, admission orders for 38.5 Septra DS tablets was written. 9 hours later, he took this dose. 14 hours after that, the patient had a seizure and a code blue was called.

*He was sent to the ICU and was there for a week (patient turned out fine)

EHR role in this errror:

*resident intended to order one Septra DS BID

*hospital EHR, Epic, was set up so that if patient weighs < 40 kg, a weight-based dose must be used (dose can't be one Septra tablet, it had to be based on mg/kg.)

*appropriate dose was 5mg/kg

*resident wrote order for 193 mg (5 milligrams x 38.5 kg = 193 mg)

*One tablet is 160, so it makes sense, you give him one tablet.

*However, EHR was set up so that if a dose is rounded and it's greater than 5% of the calculated dose, it must be confirmed and signed by the ordering physician. The order that the resident had ordered had a 17% difference.

*Resident accidentally changed the order to 160 next to the mg per kg field, resulting in 38.5 tablets.

*An alert was triggered but the resident said she gets those alerts all the time, and she didn't even look at it and overrode it

*This is an example of alert fatigue.

*The pharmacist received the alert too, saying, "Wow, that's a big overdose", and overrode the whole thing as well.

*After the resident and pharmacists overrode the alerts, it went to the pharmacy robot which brought the order to the nurse.

*The nurse that took the order was a first year nurse who happened to be floating to a research floor.

*The nurse thought it sounded like a really unusually large dose and considered asking the charge nurse, but the charge nurse was busy giving chemo, so she didn't want to bother her.

*The patient's mother told the patient he would get some different medications, so the patient didn't think anything of it.

*The bar codes were scanned and the order was confirmed, so the patient ended up taking all of those pills.

*A system to help people discern different alerts and what are more important than others can help with alarm fatigue to avoid situations like these from happening.

# data[].attributes.body
Electronic health records:

difference between:

*electronic medical records versus

*electronic health records

electronic medical record:

*all-inclusive record that is institution-specific.

*doesn't interact with outside systems

*provider-controlled within the organization

Electronic health record:

*aka lifetime patient record

*includes data from all specialties

*patients can interact with the system

what is in an electronic health record:

*Computerized provider order entry

*electronic medication administration record

*barcode medication administration

*clinical documentation

computerized provider order entry (CPOE):

*allows providers and clinicians to enter orders via the computer

*could be used for:

***medications

***laboratory/diagnostic tests ***consultations

*interfaces with other EHR

components to process orders

*allow orders to be entered, tracked, processed, updated, and completed

Electronic medical administration records (EMR):

*the medium used to view and document medication use.

*Orders are entered using CPOE and verified by the pharmacy

*EMAR includes:

***drug name

***administration time

***dose

*can be displayed in a variety of ways

*can be filtered any way the person who is giving the medication would like to see it

*works in conjunction with barcode medication administration, which also is best combined with CPOE in a pharmacy system

*designed to prevent errors during medication administration

*involves using a scanner that scans the nurse, the patient, and the medication, and it verifies the five rights

(some nurses will not scan in order to cut time, but there are scanning reports that are used in organizations that have a higher rate of scanning, such as 90 and above, will have fewer medication errors)

Clinical documentation:

*essential part of EHRs

*records, manages, and reports patient care activities through the EHR

*should support clinician workflow

*provides functionality for plans of care, decision support, viewing trending data

Specialty applications:

*aka niche systems

*another type of EHR

*goes in conjunction with the EHR

*systems designed for specific departments or groups of users

*may be stand-alone, integrated, or interfaced with EHRs.

*best interfaced with EHRs. *These can include things like: ***perioperative or surgical services systems

***maternity care

***neonatal intensive care

***emergency departments.

Ancillary systems- software programs used to support specific departments

examples:

*laboratory information system

*radiology information system, *pharmacy system

(they address specific needs of a department)

The benefits of EHRs are

*cost

*access

*quality

*safety

*efficiency of care delivery. *increase productivity

*enhance effectiveness

*provide centralized access to patient information

*improve clinical documentation

*provide resources for patient education

*provide for better reporting.

*From a state and national perspective:

***improves the coordination of care and reduces medical errors

***provides a national data set for public health and research, ***working towards that interoperability

***improves the overall health care for citizens.

Future directions of EHRs:

*personalized medicine, *customized medications

*expansion of a national EHR.

*share health information on a global level.

# data[].attributes.attachment_link.readable_text
Remote Meetings Redefined

Make meetings fun again with virtual hangout spaces, classes and conferences. For over a decade, leading companies and educators have trusted Second Life for branded social spaces for events and remote meetings.

# data[].attributes.attachment_link.title
Official Site | Second Life - Virtual Worlds, Virtual Reality, VR, Avatars, and Free 3D Chat

# data[].attributes.attachment_link.description
Second Life's official website. Second Life is a free 3D virtual world and original metaverse where users can create, connect, and chat with others from around the world using voice and text.

# data[].attributes.body
week 9

Gamification -game thinking and game mechanics in a non-game context in order to engage users and solve problems.

gamification is almost unanimously associated with the digital revolution, this is not necessarily so.

Health Games Research was a  $8.25 million program of the national Wood Johnson's Foundation's Pioneer Portfolio.

It awarded grants to different researchers that were working to improve the quality of interactive health games and increase the impact of health games on players health behaviors and outcomes.

started in 2009 and ended in 2013

seeking out to get better patient engagement in some of the patient's health conditions.

Second Life -virtual online world developed by the Linden Lab launched in 2003

by 2013, it had about a million regular users.

similar to a massively player online role playing game.

Linden Lab emphatically states that their creation is not a game because there is no manufactured conflict or set objective.

Second Life is this world where you develop an avatar and your avatar can have a variety of characteristics. You can also there's a whole culture where you can have money and you can buy different clothing and go to different clubs.

different organizations had "islands" -developed by programmers at those organizations.

IBM- meet w some of their employees who work from home in their conference rooms

Many universities had an island:

*Vassar College

***did a replication of the Sistine Chapel, which was beautiful

Im Second Life- avatar can fly so you could fly up around the artwork and actually see it up close and detailed.

Other universities established nursing simulation labs in which you could go in there and actually have a simulation lab. And those were really quite successful.

Second Life- most  universities have taken down their islands. *it's not used as much

*its primarily a more of a cultural and social gathering for people.

*different organizations that have islands

*many social things you can do.

*can fly and you can walk around, good for paraplegics or quadriplegics

***gives a sensation of being able to mobilize when they can't.

Games:

Build a Healthy Plate by the American Diabetes Association.

*select the right foods if you have diabetes.

*great for kids and helps them learn about which foods are better than others.

Diabetic Dog Game

*funded by the Robert Wood Johnson Foundation initially.

*a little dog has diabetes

*have to feed him the right foods, give him his medicine, make sure he drinks water.

*help people understand their disease by making the better choices.

Nanobot's Revenge

*targeted to children and teenagers

*kids with cancer can actually shoot and kill little cancer cells. *helpful for kids to get their frustrations out about their disease.

New:

Volunteer Science *collaboration by several colleges:

Northeastern Illinois

*and Northwestern

*trying to develop games that collect data so that they can have research data.

*turning to games to collect different data.

*Some games are survey  driven

Heroquest

*collect research about dementia.

*first signs of dementia is lose ability to do way finding.

*collecting massive amounts of data about way finding, which is really fascinating.

*longer you play, the more data points you're giving them and *hopefully will be able to advance the research in the dementia field.

gamification to help live better:

Mango Health

*collects information about your diet, your activity.

*timer or a reminder to take medication

QuitSTART

*geared towards teenagers to stop smoking

Run, Zombies Run

*app

*gamifies running

*listen to music then it will tell you that zombies are after and you try to run faster so that you can get away from the zombies

Wearables:

Thync.

*transcranial direct stimulation *$300.

*help  be calm.

*can rev you up

*worn on head.

Virtual reality goggles

*give an experience of calming or different information.

smart goggles

*for skiing or boarding

*map on screen.

*tells you how fast you're going

*statistics

Tech Tats

*paint that tattoo on skin to monitor temperature

wearables:

Fitbit

Kakoon EEG

*similar to Thync device

*calm brainwaves down so that you can relax and de-stress

Dash

*in-ear Bluetooth earbuds that  plays music & monitors  temperature and variety of other things

*data that can be used to help care for patients.

# data[].attributes.attachment_link.readable_text
The Sunbeam is a trusted friend of Maine islands. Island living presents unique challenges. Isolation can take its toll. Populations are small and gatherings are few. Going off-island for necessities or medical appointments can be very difficult: even simple chores can be complex on a remote island.

The Sunbeam and its crew bring a welcome respite, offering a warm meeting place, the opportunity to visit with crew members familiar with island living, and health care via the ship’s medical staff and state-of-the-art telehealth facilities. About 90% of residents on the outer islands we visit use the boat’s services.

Our current vessel is 74-feet long with a 22-foot beam and a seven-foot draft, built by Washburn and Doughty in East Boothbay, Maine. Launching in 1995, it was recently refitted at Front Street Shipyard in Belfast, Maine, and returned to service in 2020. She has a 450 horsepower single-screw diesel engine that can cruise at 10 knots. With its steel hull, she often serves as an ice breaker, helping to clear harbors and protect the boats moored there from ice damage.

Learn more on the History page.

# data[].attributes.attachment_link.description
The Sunbeam serves 90% of residents on Maine’s outer islands, bringing a welcome respite, a warm meeting place, and health care.

# data[].attributes.body
Telemedicine -

use of medical information exchange from one site to another through electronic communications to improve a patient's health status.

used to encompass a broader definition of remote health care that does not always involve clinical services.

examples:

video conferencing
transmission of still images
patient portals
remote monitoring
continuing medical education
call centers

services provided by telemedicine:

primary care
specialist referral services

i.e.:

*a primary care health professional providing a consultation with a patient

*a specialist providing a consultation to a physician remotely

*a provider treating a patient through teleconferincing

PCP can consult a specialist that's far away, maybe the only expert in the world, through interactive video.

Store and forward:
*a recording
*may have diagnostic images
*i.e. cardiac cath videos, vital signs, other patient data for later review

Remote patient monitoring
*another type of patient monitoring
*used a lot in home health
*different devices collect data then send that info to a more central location who can identify and assess it
*example: monitoring a specific vital sign, such as blood pressure, or heart, or EKG, or pacemakers.

Consumer medical and health information:

*the use of internet and wireless devices for consumers to obtain specialized health information or online discussions in groups or peer-to-peer support.

examples:
*monitoring CHF to help keep the CHF patient out of the hospital

*Readmissions for hospitalizations of heart failure within 30 days are not reimbursed, much attention has been paid to keeping those patients healthy as possible and in their homes.

Cardiocom now known as Medtronic

*company who puts a blood pressure cuff and scale in a patient's home.

*asks patient to take their blood pressure and weigh themselves daily.

*will determine if need intervention

*trends the different data so that you can see how that patient's doingover time.

*there ia a variety of things you can monitor

*successful in keeping people outof the hospital and understanding how to care for themselves.

telestroke programs:

*Another example of telemedicine
*usually expert is located in a larger metropolitan area where there are more of a specialty and they provide service through video and through transmission of patient data in order to manage a stroke patient in a remote area.

i.e.: a patient could arrive at an emergency department at a smaller/rural hospital or remote hospital, or a hospital that doesn't have a neurologist on staff, and they just dial up the specialist and they help to treat the patient

Sunbeam ship- provides telehealth in Maine

Amwell:

*has a number of physicians accessible through computer

*patient selects the physician they want to see.

*tell them symptoms, and they will offer you treatment through the internet through camera.

*charge a base rate of usually $50 for a visit.

*other service that Amwell sells is if you have a office practice, they will pick up all of your out-of-office calls. So you could turn over your patients to their service during non-office hours to cover for you.

*keeps people out of the ER, where it's a more costly level of care.

********
Health informatics is global.

*Canada is authorizing provincial EHR systems to be standardized, which would be great.

The National Health Service in UK is one of the most advanced and most ambitious systems, and they have a big project in standardization.

Many countries have the advantage of having a national health service, which really makes standardization much easier than the American system.

China, the largest populated country, has also made it a top priority for health informatics.

Japan is trying to get to a fully portable health records,

Malaysia, as well as Scotland, have efforts in this realm.

key initiatives:

European region: the first health action plan also started about the same time as US.

have opened smart services for their patients

are trying to evaluate and build infrastructure to demonstrate cross-border interoperability.

US is trying to get interoperability as well.

European Federation for Medical Informatics

*has 30 different countries and 16 working groups

In Asia-Pacific area

*started their initiative in 2005, and they have an

*Asian Pacific Association of Medical Informatics

*projects include personal health cards, digital clinical histories, electronic prescriptions, internet applications, health portals, social webs, risk management, telemedicine, regional call centers, and digitization of documentation.

Taiwan

*had one of the  more advanced progress in becoming completely nationalized.

*have a national health system

*have national health insurance

African region:

*working on digitizing in many different ways.

*created an organization to help push that forward.

*underdeveloped countries in Africa still have paper records

+smartphones are being donated in order to collect some of this public health information.

World Health Organization:

*supporting e-health initiatives

*established a global observatory for e-health to monitor and analyze the evolution of e-health

*working with International Health Terminology Standards Development Organisation.

for standardization of basic terms and include all the different types of languages available.

Global Health Technology Coalition:

*a group of more than 25 non-profit organizations to increase the awareness and the urgent need for technologies that save lives

*funded in part by the Bill and Melinda Gates.

We need:

*tools for the development of national or regional e-health initiatives and strategy.

*need to collaborate with developing these national, regional, and international initiatives so that we all can share some information and look at some technology together and work with these organizations to build that capacity.

*cooperation and information exchange among all the members.

# data[].attributes.body
Health Information Exchange:

*allows doctors, nurses, pharmacists, and other health care providers to securely share a patient's vital medical information electronically.

*Patient's information about  visits, labs, and X-rays are sent to the HIE

*health information is shared electronically between health care providers before the patient arrives for an appointment or goes to the pharmacy to pick up a medication.

*HIEs connect with hospitals, labs, physician practices, and pharmacies.

Advantages of HIE:

*reduce the need for patients to transport or relay their:

***medical history

***lab results/images

***prescriptions

*Timely sharing of patient information can better inform decision-making at the point of care and allows providers to avoid readmissions and medication errors, improve diagnoses, decrease duplicate testing, all which help save health care dollars.

Every state received funds to modernize how patient health information is shared.

Each state has adopted a HIE at a different pace, but all have a strategic plan to put one in.

Maine:

*early adopter of HIE

*almost all hospitals and physician offices participate in some way

In the future, the hope is to connect patients and health plans to the HIE.

One of the biggest challenges for HIE is to continue to operate.

*All were given grants to get started

*Some have continued to be funded by grants.

*Some are trying to find ways to monetize their work by charging membership fees or providing other services.

Today's main HIE offers a robust data analytics service which they charge for.

The HIE is a valuable service, and it is our first attempt to start to collect information.

Data - raw numbers collected and stored at the level of which the unit of analysis was observed.

*Data must be processed to be of practical use.

Statistics - analyzing raw data reported in a meaningful format.

data sets -major unit of data storage and retrieval consisting of collection of data in a prescribed arrangement or format.

*Data sets have documentation, like an owner's manual.

*These often occur in either another document or an attachment or a tab on the data set itself.

*Most will tell you what each number in the data set or each condition in the data set is referring to.

*Good data documentation will include:

*the context

*the method it was collected, *protocols

*scale

*software and instruments used in data collection

*detailed outline of data structure

*file types used

*methods used for data validation (how do they know their data is good quality)

*how they clean the data

*how data sources were used

*modification to data over time

(if it's a longitudinal study and things have changed, this needs to be explained)

*data confidentiality, access, and use conditions

Most data sets are results of research and have gone through an internal review board which drives or is requiring them to provide this level of describing confidentiality.

Data documentation

1. Metadata

*Metadata is a set of data that describes and gives information about other data.

1. Ontologies - a set of concepts and categories in the subject area or domain that shows their properties and its relationships between them. So this is how they relate to other things. Medical subject headings might be the ontology they're using. The ICD might be another one. And then the LOINC code, which is the Logical Observation Identifier Names and Codes, which is used primarily in laboratory systems.

data sets:

*data collected to meet the needs of the collector.

i.e.: researchers

Organizations may have biases.

example: pharmaceutical companies who sponsor research they pay for may be biased towards a certain drug

Biases can determine what data is collected, how they are collected, and what is reported.

Data source notes describe the reasons for the data collection and method used.

Kaiser Family Foundation:

*produces large amount of data sets that are available for no charge.

*a great place to start looking for data

*variety of topics

*site is easy to read

private data:

*data sources not available to the public

example: electronic health records protecting patient health information through HIPAA

example: insurance claim data.

Public data:

*available to anyone

*retrievable from many websites

*reported data  (example: immunization rates might be available from the state)

*Claims data (They are not identifiable)

*Disease registries

(example: diabetic registry,

The CDC has a lot of these registries)

*Health surveys (example: Nain Survey)

*clinical trials data that are publicly available (example: Kaiser Family Foundation punlishes this type of data)

different types of data:

*administrative data- organizations report this data

(example: H-CUP- free online query system based on data from the Health Care Cost and Utilization Project. It provides access to health statistics and information on hospital inpatient emergency department utilizations.

States require some diseases to be reported. )

*Claims data - based on ICD-10 code

*the sources of claims data can be obtained by Medicare, Medicaid, and even in some commercial health plans.

*Disease registries -most of these require some sort of membership or approval. There are cardiac, diabetes, and GI registries available for example

*health surveys- provide an accurate evaluation of population health. (example: Nains)

*Clinical trial databases- Most are private, some are publicly-funded.

# data[].attributes.attachment_link.description
12 % physicians successfully participating with letter improvements. If you are 99.5 % successful in meaningful use, you are 100% unsuccessful. "I did not go to medical school to jump through bureaucratic hoops. I now spend more time on my Electronic Medical Records than i do taking care of patients."

# data[].attributes.attachment_link.title
The HITECH Act: Electronic Health Records and Meaningful Use

# data[].attributes.body
The implementation of electronic health records help to avoid dangerous medical mistakes, reduce costs, and improve care.

Changes to start using EHR started taking flight when

George W. Bush established the Office of the National Coordinator for Health IT in 2004 through an executive order.

In 2009, Obama implemented the American Recovery and Reinvestment Act, which funded many shovel-ready programs.

Then, The Health Information Technology for Economic and Clinical Health (HITECH) Act promoted health information technology and the electronic exchange of information to improve:

*quality health care

*safety

*efficiency

In 2010 incentive money was needed in order to make this happen.

Therefore, $30 billion was allocated towards the Centers for Medicare and Medicaid (CMS) incentive program to provide financial incentives to get hospitals and provider practices to implement EHRs.

This program was successful, and by 2014, hospitals had an EHR adoption rate of about 80%.

Now, 90% of hospital organizations and 60% of physician offices have clinical information systems.

"Meaningful use" was a part of the  CMS  incentive program and it has "four buckets":

1. buy a certified EHR (Vendors of EHR's had to get certified by CMS)

2. capture data

3. move the data

4. report data

Also, meaningful use was divided into three stages:

1. (2011-2012) focused on capturing data and sharing it
2. (2014) show advanced clinical processes
3.(2016)  demonstrate improved outcomes

More details about Meaningful use Stage 2 Objectives:

*The EHR needed to be able to have patient health information secured. Security risk analysis and security updates must be able to be done in order to protect the patient health information.

*Clinical decision support: The system needs to have the ability to be used to improve performance using clinical decision supports.

Example: an alert when you're ordering a medication that their patient has an allergy

or clinical guidelines embedded in the EHR

*Computerized Provider Order Entry (CPOE) - the physician or the provider has to put medication, laboratory, and radiology orders in the EHR.

Before this, they had to write it down on a piece of paper and someone had to put it on a lab or radiology slip and then take the slip to the lab or radiology department in order for that to be ordered.

There were many transcription errors with this method such as the wrong test being ordereddue to not being able to

read somebody's handwriting,

Computerized Provider Order Entry reduced a lot of those errors.

*E-prescribing- where you electronically send the prescription to the pharmacy, and the pharmacy accepts it.

this has reduced a lot of the fraudulent prescriptions because prior to e-prescribing, providers would write out a prescription on a prescription pad, and the patient would take that to the pharmacy.

Even though security paper was used, people were able to modify those things.

*Health Informatiom Exchange is the EHR ability to  transfer patient's information and summary of what was done for the patient to another setting when referring or transferring the patient to another provider.

*Patient-specific education:

EHR's ability to have patient-specific education resources that can be printed out and given to the patient.

*Medication reconciliation: The EHR must have information of the patient's current medications and this must be able to be sent and received to and from different provider settings. Medication reconciliation needs to happen at every encounter.

*Patient Electronic Access:  Hospitals and providers need to provide patients with the ability to view online, download, transmit their health information, and request health records electronically

within four business days of the information being available to the provider. An example of this would be with the use of patient portals.

*Secure messaging:

the ability to use secure messaging to communicate with patients relevant health information. Many people use the patient portal secure messaging feature.

*public health: submitting electronic public health data to a public health agency such as

electronically transmitting immunization records to a state office that collects immunization information or the electronic reporting of an outbreak of a specific illness.

Meaningful Use has very specific rules and guidelines.

There are thresholds for each objective and they are measured. The provider must attest that the objectives are being done to get additional reimbursement for them.

Some organizations have a quality control person  to monitor this. The reimbursements for meeting the Meaningful Use objectives are of a significant financial amount.

# data[].attributes.body
The Nelson continuum is a conceptual framework to turn data into wisdom.

Example: a data point of 86.

86 is just a number. We don't know what it means or what to do with it.

Context- would be that 86 came from a thermometer at 2 o'clock in the afternoon in the month of July in Maine.

86 now has meaning.

If this is applied to make plans for the day, such as a beach day, the data 86 turned into wisdom which guides us to make choices.

EHR systems are programmed with algorithms that can provide contexts in order to understand data so that it can be transformed into knowledge and wisdom.

ICD-10 codes are structured data that are used internationally to code medical claims so that a provider can get paid the interventions that are done.

The first three numbers of an icd10 code is the category and the rest of the number will specify the patient's condition even further.

Acquiring a new EHR:

Changing systems is extremely costly, about a multi-million dollar process.

These characteristics of an organization must be taken into account if considering a new EHR:

size of organization

type

complexity of the organization

unique cultural aspects of the  organization

strategic vision and alignment of the organization as well as the technology department strategic vision and plan

Then, the organization needs to evaluate systems.

A System Development Life Cycle (SDLC) - a framework that is used when acquiring a new EHR that contains a series of sequential logistical steps to understand the process of developing, implementing, and using an information system.

The processes to acquire a new information system typically start with a Request for Information (RFI)- a document that includes questions answered by vendors, such as vendor experience, product, and patient communication.

The next step is a Request for Proposal (RFP)- a more complete and formal document that includes cost and financial data and helps  develop a negotiation process.

If is important that it includes a vendor evaluation criteria to hold the vendor accountable in meeting the customer's needs.

The vendor evaluation criteria includes experience, staff strength, market and industry understanding, service and cost.

Many organizations will hire a consultant to help with making a choice on a vendor.

Its important to establish a relationship with potential vendors because you have to be in sync with priorities and agree on criteria for a successful implementation.

Once a vendor is chosen, there must be detailed project management plan for implementation with time frames. A consultant can be hired for that or the vendors can help.

Some important things that need to be planned for a new EHR:

Where hardware and wiring needs to be installed

the roles and responsibilities for every step in that project.

# data[].attributes.headline
IBM website explanation of interoperability in health care

# data[].attributes.subject
IBM website explanation of interoperability in health care

# data[].attributes.body
https://www.ibm.com/topics/interoperability-in-healthcare

# data[].attributes.attachment_link.readable_text
What is interoperability in healthcare?

Interoperability in healthcare refers to timely and secure access, integration and use of electronic health data so that it can be used to optimize health outcomes for individuals and populations.

Health data has always been challenging to access and share in a secure manner. The nature of health data creates a paradox: It's difficult to share because it's sensitive and requires a high level of privacy and security, yet the inability to access it when it's needed has potential to cause significant harm. A lack of interoperability can result in an incomplete understanding of an individual's or population's health needs, which can lead to poorer outcomes and higher costs.

As populations around the world age and people live longer, interoperability and data sharing are going to become increasingly critical for delivering effective healthcare. In the United States, the Agency for Healthcare Research and Quality has estimated that two out of three older Americans have at least two chronic behavioral or physical conditions. Treatment for people with multiple chronic conditions currently accounts for an estimated 66% of US healthcare costs.

In their nationwide roadmap (PDF, 3.5 MB), the Office of the National Coordinator for Health Information Technology (ONC) says the use of electronic health records (EHRs) has dramatically increased in the United States. Many hospitals now have routine access to medical records and patient data from outside providers, yet less than half of hospitals are integrating the data they receive into individual patient records. So although access to vital clinical data has improved, there's still a lot of work that needs to be done to bring stakeholders together to create an integrated data ecosystem.

In addition to helping physicians and other healthcare providers see a more complete view of their patients, health data interoperability helps organizations across the healthcare industry. If health information systems were more integrated, then health plans would be able to develop a better understanding of their utilization rates and demand for services. Government service providers would be able to access population data to see trends and meet their citizens' needs. Also, life science organizations would be able to leverage robust datasets to drive faster, more informed research.

With better interoperability, organizations would be able to stop regarding individuals as a patient one day, a health plan member the next and a consumer of health apps the next. Instead, decision-makers across the industry would be able start looking at how people access and use health information, regardless of its source, to drive better models of care, pursue better patient safety and improve experiences for the people they serve.

Healthcare interoperability benefits

Better care coordination

With access to data, clinicians have an easier time accessing a patient's most important health information, which can lead to fewer repeat tests, prevent inadvertent treatment interactions and reduce miscommunications.

Higher performance

When data can be combined more easily, it can also be analyzed more easily. Interoperability makes it possible for organizations to study data trends, past performance and make data-driven improvements in patient care and other areas.

Better experiences

Data interoperability can reduce the amount of redundant administrative work both within and outside organizations, creating a more satisfying experiences both for employees and for those they serve.

Fast Healthcare Interoperability Resources, also known as FHIR, is an open source standards framework for healthcare data that builds off of a previous standards framework called HL7. FHIR was created to make it easier for healthcare data to move from one system to another.

FHIR organizes data into resources like patient, conditions, medications and provides a standardized structure for how that data is organized and interpreted by different computer systems or applications. FHIR can also be used to structure financial data and workflow data, such as claims information, appointments and more.

Many major healthcare systems in United States have already adopted FHIR in their health IT practices. Medicare's Blue Button 2.0 initiative is based on FHIR and the Veteran's Affairs Administration has developed a FHIR platform called Lighthouse. Both provide platforms for patient access to healthcare information through FHIR.

The National Coordinator for Health IT in the United States has made FHIR a key part of the nationwide interoperability roadmap (PDF, 3.5 MB). New government regulations and interoperability rules are requiring wider adoption of FHIR, so it's vital for healthcare organizations, especially for ones that receive payments for Medicare or Medicaid services, to understand FHIR and incorporate it into their interoperability strategies.
Learn more about IBM FHIR Server

Modern consumers have high expectations when it comes to accessing information, and many now expect to have quick and continuous access to records about their health and care. That's why many healthcare organizations are building health information exchanges (HIE), which are specialized networks that rely on interoperable systems to share electronic health information seamlessly and securely.

Even though the adoption of EHRs was a good first step towards building HIEs, there are still many challenges that need to be overcome to achieve the level of interoperability needed to obtain the full benefits of HIEs. These challenges include:

Lack of standardization: Although standard record formats like FHIR and HL7 are becoming more common and new regulations are pushing EHR vendors to provide APIs that support interoperability, many providers and healthcare systems use customized EHR systems that can be hard to convert to a standard format and shared with others.

Security: Healthcare organizations can find it hard to balance the need for health information to be accessible with the need to secure sensitive information and maintain patient privacy, especially with the increasing number of cybersecurity attacks on healthcare systems (PDF, 1.3 MB).

Consent: By building digital health systems in which health information flows freely from provider to provider, it's not always clear when patient consent is needed and what level of consent is needed. Healthcare organizations are understandably cautious about this and tend to error on the side of not sharing information.

Professional burdens: When new tools for recordkeeping are introduced, people need to learn how to use them. Healthcare professionals are often wary about new systems since EHR systems often do a better job supporting administrative and billing workflows than clinicians' needs.

These challenges are not insurmountable. With advances in cloud computing, especially hybrid cloud, it's become easier for organizations to move and secure data in a consistent way. Cloud environments provide opportunities for organizations to build data pipelines that standardize data to an industry-standard format like FHIR and provide secure access to people who need it - whether they're payers, providers or patients themselves.

Learn about enabling health data interoperability
Read the article

In 2016, President Obama took a major step to solve information blocking by signing the 21st Century Cures Act, which requires EHR systems to provide a patient-facing API to maintain their federal certification. In 2020, the Centers for Medicaid & Medicare Services (CMS) issued a rule requiring health plans and providers who receive federal funds from their programs must take steps to make health information easier to access.

Most of the policies focus on encouraging payers to implement application programming interfaces (APIs) and data exchanges that provide secure access to their provider directories, patient claims data and other resources that would make it easier for data to be accessed in a timely manner. This access would give patients, as well as providers and payers, a more holistic view of the care people receive and support broader public health efforts.

See how mandatory interoperability standards will affect your organization.
Learn more about the CMS regulations

While many healthcare experts and leaders agree that better interoperability would improve healthcare overall, there are common challenges that healthcare organizations tend to face as they work on making their data and systems more interoperable. Let's explore those challenges and how organizations can overcome them:

Disjointed coordination
Improving interoperability requires strong coordination between different organizations, regulators and leaders as well as coordination within organizations. Regulators provide standards and rules for healthcare organizations to follow but organizations that want to be proactive about interoperability should consider creating a dedicated interoperability strategy and make interoperability planning a priority.

Limited budgets
Not all organizations have the financial or technical resources they need to invest in the technical resources needed to build a truly interoperable system. There may be some government grants available to update health records systems, so organizations should check to see if they're eligible. Many cloud vendors also offer pay-as-you-go payment models that could make technical expenses more affordable and predictable.

Diverse technology needs
Organizations need to follow different rules and regulations depending on what type of care they provide and where they're located, so many organizations have highly customized data. Organizations can help connect different internal and external systems through a hybrid cloud platform that gives them options to combine and integrate their data without sacrificing the customizations they need.

Legacy systems
Healthcare organizations with older legacy systems face the dual challenges of modernizing their systems while also meeting interoperability requirements. Organizations can meet both goals using a hybrid cloud approach to extract data from legacy systems and make it more accessible for modern applications and programs. This approach gives organizations the option to keep data moving while they work on updating their systems.

Interoperability for healthcare has four different levels that have been defined by informatics experts and the Healthcare Information and Management Systems Society (HIMSS). Some of these levels can be achieved today with existing healthcare IT architecture and IT systems, while others will require innovation and additional developments in patient-centered technology.

These levels include:
Foundational
This level of interoperability, also known as simple transport, is the most basic. Data is securely transferred from one system or device to another without interpreting the data or transforming it into a particular format. For example, a nurse downloads a PDF file of a patient's latest lab results from the lab's results portal, then manually enters the data into the patient's health record.
Structural
When structural interoperability, or structured transport, is achieved, all the data is standardized to a particular format so it can be interpreted by multiple systems or devices. This data is organized in a particular order so the receiving system can automatically detect specific data fields. Data standards like FHIR and HL7 provide structural interoperability so records can be consistent, centralized and easy to move between systems.
Semantic
The semantic level of interoperability, or semantic transport, involves exchanging data between systems with completely different data structures. Imaging systems provide a simple example - there are many specialized DICOM and non-DICOM formats for images. With semantic interoperability, images could be transferred from one system to another, interpreted and incorporated into the new system regardless of the image's original format or source. Yet determining what data to collect and transfer can be difficult, since systems have different ways of presenting the same information. For that reason, some experts argue artificial intelligence will be needed to achieve full semantic interoperability.
Organizational
Organizational interoperability involves the seamless exchange of data between various organizations with different requirements, regulations and goals. To achieve this level of interoperability, there must be policy and governance innovations as well as technological innovations to ensure consent, security and integrated workflows move smoothly between different groups. Though some experts say semantic is the highest level of interoperability, others say it is organizational interoperability.

Discover the stages of maturity along the path to interoperability
Explore the stages

# data[].attributes.attachment_link.description
Interoperability in healthcare refers to the secure access and integration of electronic health data so it can be used to optimize health outcomes.

# data[].attributes.body
Interoperability- when two or more systems can exhange information and then use the information. Tools of health information must be standardized like physicians electronic health records so that they can be shared between doctors, hospitals, pharmacies, health plans, and patients. The transition from paper based records to electronic health records has helped attain interoperability. The goal is for patient information to be available when and where patient needs it to save time, money, and lives. Clear standards are being developed to make sure systems communicate with each other.

Its important to use standardized terminology when documentin problems, interventions, and outcomes in order to compare interventions and their outcomes.

Data entry should be in defined fields with the use of the same terms and free text should not be an option.

Standard terminology will allow for the retrieval of coded data that is easily compared and easily developed so that we can see the patterns and trends.

Also, in order to determine how to take an approach on  problem, we need common links and standardization that will allow this data to be stored and retrieved to improve decision making.

There should also be a shared  understanding across the continuum of care.

Big Data- a massive pool of data from multiple sources that can be used to identify and monitor health needs and outcomes. It is most effective if we can all use a standardized terminology. IBM Watson is  one of the most popular tools used to process Big Data.

Organizations like AHRQ and NCQA )National Committee for Quality Assurance), and NSF are looking at different quality measures for auditing quality of service and benchmarking.

standardized terminology supports research activities by being used to look at data.

standardized vocabulary should be used to enable and report externally specified health statistics, both clinically and educationally, so that they can be compared.

standardization should also be used to identify individuals in need of proactive intervention

so that how to care for individuals is clear.

Terms- words used to refer to a concept (if more than one term for a concept= synonym)

context - needed to interpret a term. if the context is unknown, errors can occur.

Sometimes a context might be right, but the term is wrong, or there is a translation error.

Example: good- can mean: well-behaved, favorable character, pleasant, satisfactory, deserving of respect.

Synonyms are auspicious, skillful, excellent, just, honest, kind, virtuous, and helpful.

"good," has all these different meanings. we need to know the context to know which good we're talking about.

standardized language is important to get the terms all the same, but context also needs to be there so we can understand the meaning.

# data[].attributes.body
https://www.himss.org/what-we-do-initiatives/technology-informatics-guiding-education-reform-tiger

# data[].attributes.body
QSEN, AACN, and the TIGER are three major initiatives that  been driving nursing education to include informatics as part of the curriculum.

Quality and Safety Education for Nurses (QSEN) - formed by nursing leaders in 2005, in response to a call by the IOM to improve the quality of health care.

QSEN has six competencies:

1. patient-centered care

2. teamwork

3. collaboration

4. evidence-based practice

5. quality improvement

6. informatics.

Each competency is divided into three categories: knowledge, skills, and attitudes.

The American Association of Colleges of Nursing (AACN) provides accreditation for nursing programs and has developed standards and essentials to the delivery of nursing education which includes education in informatics in the baccalaureate, masters, and doctorates level.

The TIGER Initiative Foundation was formed in 2011. They engage diverse stakeholders to further its mission of advancing the integration of health informatics to transform practice, education, and consumer engagement.

Its focus is to prepare better clinical workforce to use technology and informatics to improve the delivery of patient care. In 2014, it transitioned to HIMSS (Healthcare Information and Management Systems Society) the leading not-for-profit organization focused on better health through information technology.

Tiger initiative - began in 2005, they recognized needed nurses engaged in the process of placing health information technology throughout the country.

The seven steps of Tiger include communication and collaboration, Education, Informatics design, Information Technology, culture, management and leadership, and Policy. These key “pillars” are both interdependent and essential for creating an environment that will enable nurses to use informatics to provide safer, higher-quality care.