BACKGROUND AND OBJECTIVES Patient navigators and enhanced personal health records improve the quality of health care delivered in other disease states. We aimed to develop a navigator program for patients with CKD and an electronic health record-based enhanced personal health record to disseminate CKD stage-specific goals of care and education. We also conducted a pragmatic randomized clinical trial to compare the effect of a navigator program for patients with CKD with enhanced personal health record and compare their combination compared with usual care among patients with CKD stage 3b/4. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Two hundred and nine patients from six outpatient clinics (in both primary care and nephrology settings) were randomized in a 2×2 factorial design into four-study groups: (1) enhanced personal health record only, (2) patient navigator only, (3) both, and (4) usual care (control) group. Primary outcome measure was the change in eGFR over a 2-year follow-up period. Secondary outcome measures included acquisition of appropriate CKD-related laboratory measures, specialty referrals, and hospitalization rates. RESULTS Median age of the study population was 68 years old, and 75% were white. At study entry, 54% of patients were followed by nephrologists, and 88% were on renin-angiotensin system blockers. After a 2-year follow-up, rate of decline in eGFR was similar across the four groups (P=0.19). Measurements of CKD-related laboratory parameters were not significantly different among the groups. Furthermore, referral for dialysis education and vascular access placement, emergency room visits, and hospitalization rates were not statistically significant different between the groups. CONCLUSIONS We successfully developed a patient navigator program and an enhanced personal health record for the CKD population. However, there were no differences in eGFR decline and other outcomes among the study groups. Larger and long-term studies along with cost-effectiveness analyses are needed to evaluate the role of patient navigators and patient education through an enhanced personal health record in those with CKD.

BACKGROUND:The Network of Digital Evidence (NODE) was formed to further advance the field of health information technology (HIT) and evidence-based digital medicine at different healthcare institutions nationwide. As the NODE network reviewed the state of the field, it was noted that despite substantial financial and human capital investments, the processes and results of HIT innovation seem chaotic and subpar, especially in comparison to the more well-established drug and device industries. During the course of this white paper, we will explore the causes for this observed phenomenon as well as propose possible solutions to improve the state of HIT.METHODS:We compared the entire process of discovery, proof of concept, Food and Drug Administration (FDA) review, and postmarket monitoring and distribution/implementation of HIT innovations to the equivalent processes for drugs and devices. Whereas drug and device innovations are subject to a standardized pipeline of production, HIT innovations are not held to equivalent standards.CONCLUSIONS:As a result, HIT lags behind the more mature drug and device industries in producing effective and reliable products. This leads to an inefficient use of already scarce healthcare resources. The authors believe that the HIT industry must adopt many of the mechanisms implemented by the drug and device industries as dictated by their innovation pipelines of discovery, proof of concept, FDA review, and postmarket monitoring and distribution/implementation. We propose an eight-point plan to fundamentally evolve the HIT lifecycle, including reforms for institutions such as neutral government agencies, new health system boards and management systems, modified incentive structures, improved relationships with financial investors and start-ups, patient engagement, and enhanced mechanisms to improve HIT adoption.

Background: Chronic Kidney Disease (CKD) is a public health problem and there is a scarcity of type 2 CKD translational research that incorporates educational tools. Patient navigators have been shown to be effective at reducing disparities and improving outcomes in the oncology field. We describe the creation of a CKD Patient Navigator program designed to help coordinate care, address system-barriers, and educate/motivate patients.Methods: The conceptual framework for the CKD Patient Navigator Program is rooted in the Chronic Care Model that has a main goal of high-quality chronic disease management. Our established multidisciplinary CKD research team enlisted new members from information technology and data management to help create the program. It encompassed three phases: hiring, training, and implementation. For hiring, we wanted a non-medical or lay person with a college degree that possessed strong interpersonal skills and experience in a service-orientated field. For training, there were three key areas: general patient navigator training, CKD education, and electronic health record (EHR) training. For implementation, we defined barriers of care and created EHR templates for which pertinent study data could be extracted.Results: We have hired two CKD patient navigators who will be responsible for navigating CKD patients enrolled in a clinical trial. They have undergone training in general patient navigation, specific CKD education through directed readings and clinical shadowing, as well as EHR and other patient related privacy and research training.Conclusions: The need for novel approaches like our CKD patient navigator program designed to impact CKD care is vital and should utilize team-based care and health information technology given the changing landscape of our health systems.

Background: Higher serum phosphorus is associated with an increased mortality among those with chronic kidney disease (CKD). We examined the practice patterns of phosphate binder use to lower serum phosphorus levels and their associations with mortality in the non-dialysisdependent CKD population. Methods: We examined the factors associated with the use of calcium and non-calcium phosphate binders in those with stage 3 and 4 CKD (eGFR 15 - 59 mL/min/1.73 m(2)) using logistic regression models. The associations between phosphate binder use and mortality were studied using propensity based analysis. Results: Out of 57,928 patients with eGFR 15 - 59 mL/min/1.73 m(2), 13,325 (23%) patients had serum phosphorus levels measured. 945 patients were prescribed phosphate binders, with 238 (25%) of them prescribed non-calcium-based phosphate binders and the rest calcium-based phosphate binders. Higher BMI, higher serum phosphorus, and higher serum calcium were associated with higher odds of being prescribed a non-calcium-based binder. Phosphate binder use was not significantly associated with mortality in either the entire cohort or the matched cohort in the analysis limited to those who were treated for at least 6 months. In the matched cohort, those who were treated for 1 year with a phosphate binder had a non-significant lower mortality rate (hazard ratio (HR): 0.85, 95% CI 0.66, 1.10). Conclusions: Phosphate binder use for 6 months and 1 year was not associated with reduced mortality in those with stage 3 and stage 4 CKD.

Background: Whether chronic kidney disease (CKD) recognition in an electronic health record (EHR) problem list improves processes of care or clinical outcomes of end-stage renal disease (ESRD) and death is unclear. Methods: We identified patients who had at least 1 year of follow-up (2005-2009) in our EHR-based CKD registry (n = 25,742). CKD recognition was defined by having ICD-9 codes for CKD, diabetic kidney disease, or hypertensive kidney disease in the problem list. We calculated proportions of patients with and without CKD recognition and examined differences by demographics, clinical factors, and development of ESRD or mortality. We evaluated differences in the proportion of patients with CKD-specific laboratory results checked before and after recognition among cases and propensity-matched controls. Results: Only 11% (n = 2,735) had CKD recognition in the problem list and they were younger (68 vs. 71 years), a higher proportion were male (61 vs. 37%) and African-American (21 vs. 10%) compared to those unrecognized. CKD-specific laboratory results for patients with estimated glomerular filtration rate (eGFR) 30-59 including intact parathyroid hormone (23 vs. 6%), vitamin D (22 vs. 18%), phosphorus (29 vs. 7%), and a urine check for proteinuria (55 vs. 36%) were significantly more likely to be done among those with CKD recognition (all p < 0.05). Similar results were found for eGFR <30 except for proteinuria and in our propensity score-matched control analysis. There was no independent association of CKD recognition with ESRD or mortality. Conclusions: CKD recognition in the EHR problem list was low, but translated into more CKD-specific processes of care; however ESRD or mortality were not affected.

Introduction: According to guidelines patients receiving a lipid-lowering agent at discharge for stroke should receive follow-up lipid profile. Our measure takes the currently collected STK-6, one step further and tries to identify whether these patients receive follow-up lipid testing by comparing non-abstracted electronic health record data to abstracted data. Methods: Data was extracted from the Cleveland Clinic EMR (Epic Systems, Inc.) utilized by the Cleveland Clinic Health System (10 hospitals and 16 family health centers). The cohort was based on patients with an admission for stroke from 2008 to 2012 utilizing STK-6 criteria. We examined this cohort for whether they received a lipid panel within the 12 months after the discharge date and limited patients to those that received follow up encounters at our healthcare system. Demographic factors including age, gender, race, ethnicity, distance to hospital, primary diagnosis for hospitalization and presence of comorbid conditions were also extracted. This data was compared to our abstracted publically reported STK-6 data which comes from claims data. Results: Of the 508 patients included in results for STK-6 reporting, only 391 (77%) were also identified through the EMR. Of these, 274 patients had follow up at least one year within the healthcare system. Only 97(35%) patients had lipid panel lab results indicated in the EMR within one year of discharge. Testing was not statistically different based on patient characteristics: patients < 70 yrs vs 70+ (37% vs 30%, p=0.27), whites vs non-whites (35% vs. 36%, p=0.93), males vs. females (39% vs 30%, p=0.12). There was no significant difference in distance to the hospital from patients primary residence either between those without and with follow up lipid testing (mean distance=39 miles vs.17 miles, p=0.22). Conclusions: Follow up lipid testing following stroke discharge is not consistently performed among patients treated at a large healthcare system. There are not any highly significant differences in testing based on patient demographic characteristics or distance to the hospital. Further understanding of the reasons for poor follow up testing is required as well as evaluating concordance of the data pulled from the EMR when compared to abstracted data.

Electronic health records (EHRs) were first developed in the 1960s as clinical information systems for document storage and retrieval. Adoption of EHRs has increased in the developed world and is increasing in developing countries. Studies have shown that quality of patient care is improved among health centers with EHRs. In this article, we review the structure and function of EHRs along with an examination of its potential application in CKD care and research. Well-designed patient registries using EHRs data allow for improved aggregation of patient data for quality improvement and to facilitate clinical research. Preliminary data from the United States and other countries have demonstrated that CKD care might improve with use of EHRs-based programs. We recently developed a CKD registry derived from EHRs data at our institution and complimented the registry with other patient details from the United States Renal Data System and the Social Security Death Index. This registry allows us to conduct a EHRs-based clinical trial that examines whether empowering patients with a personal health record or patient navigators improves CKD care, along with identifying participants for other clinical trials and conducting health services research. EHRs use have shown promising results in some settings, but not in others, perhaps attributed to the differences in EHRs adoption rates and varying functionality. Thus, future studies should explore the optimal methods of using EHRs to improve CKD care and research at the individual patient level, health system and population levels.

CLEVELAND CLINIC has embraced social media as an opportunity to innovate how it presents its brand and to engage patients and the community in learning about health. As many health systems have, Cleveland Clinic began with a basic presence on Facebook, Twitter, and YouTube. Since then, the focus has moved to how to engage patients through these new technologies. As Thielst notes in her feature, the Clinic's journey started in early 2009 with the chief marketing officer's straightforward presentation to the board about the value and strategy of using social media. Cleveland Clinic developed a policy that cautions employees about improper social media use but also opens its social media channels to them and invites their participation. The social media committee included employees from a range of departments beyond marketing and communications, including education, research, and the medical library. From this foundation, the social media initiative flourished (Cooperstein 2011). Cleveland Clinic seeks to bring medical experts to followers through several Twitter postings per day. Daily health tips and weekly chats allow followers to hear from and interact with experts. News and links about important studies are posted regardless of whether those studies are led by the Clinic. Other regular topic areas include news about innovations and information about specific diseases and conditions. Through Twitter, Cleveland Clinic is proactive about complaints, responding to them within two hours. Continuous monitoring of mentions of Cleveland Clinic lets the staff catch complaints early, and tweeters are asked to contact the ombudsman to resolve their complaint quickly, offline. One follower marveled on Twitter afterward about how quickly an appointment problem was resolved; the follower didn't know that someone was actively listening. Such proactivity helps stave off the viral spread of negative word-of-mouth that some organizations have experienced in social media use (Shirley 2009). Listening is a key part of Cleveland Clinic's social media strategy. The organization surveys Twitter followers semiannually to gauge their topics of interest and learn what other healthcare organizations they follow. The top three topics in which followers consistently report interest are medical breakthroughs and innovations, disease- or condition-specific information, and wellness tips. Cleveland Clinic's Facebook presence lets the organization create a connection with patients and the community, humanizing the large organization through direct interaction. Facebook content consists of question and answers, "Did you know" segments about the Clinic's history, and health information from physicians. In semiannual surveys, Facebook followers share what they expect from an academic medical center's Facebook page. Their responses are similar to the Twitter users'; the Clinic's Facebook followers are twice as likely to share medical breakthroughs than patient stories. Cleveland Clinic started a YouTube channel in 2009, and in its first year 70 videos were posted and the channel received 60,000 views. Now the channel includes more than 800 videos and has received 700,000 views. To make the channel more search friendly, the Clinic focused on appropriate tagging of videos and use of search engine optimization. The strategy has paid off: YouTube is the Clinic's biggest social media success. Videos cover the same areas as the other social media profiles do: discoveries, disease information, health tips, and patient stories. SOCIAL MEDIA INNOVATIONS Let's Move It (www.letsmoveit.org) is a wellness initiative launched in 2010 that uses a dedicated website, videos, Twitter, videos, a mobile app, and the hospital's main Facebook page to encourage the community to move from inactivity to activity. The site's videos center on fitness questions answered by Cleveland Clinic physicians and general managers and players from major league sports teams, and the Lef s Move It theme music and videos are played at sporting events. …

BACKGROUND AND OBJECTIVES:Chronic kidney disease (CKD) is increasing, and outcomes-related research from diverse health care settings is needed to target appropriate efforts and interventions. We developed an electronic health record (EHR)-based CKD registry at the Cleveland Clinic and validated comorbid conditions. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS:Patients who had at least one face-to-face outpatient encounter with a Cleveland Clinic health care provider and (1) had two estimated GFR values <60 ml/min per 1.73 m(2) >90 days apart as of January 1, 2005 and/or (2) were patients with International Classification of Diseases-9 (ICD-9) diagnosis codes for kidney disease were included. RESULTS:Our registry includes 57,276 patients (53,399 patients met estimated GFR criteria and 3877 patients met ICD-9 diagnosis code criteria) as of March 2010. Mean age was 69.5 ± 13.4 years, with 55% women and 12% African Americans. Medicare is the primary insurer for more than one half of the study cohort. The κ statistics to assess the extent of agreement between the administrative dataset extracted from the EHR and actual EHR chart review showed substantial agreement (>0.80) for all conditions except for coronary artery disease and hypertension, which had moderate agreement (<0.60). CONCLUSIONS:Development of an EHR-based CKD registry is feasible in a large health system, and the comorbid conditions included in the registry are reliable. In addition to conducting research studies, such a registry could help to improve the quality of care delivered to CKD patients and complement the ongoing nationwide efforts to develop a CKD surveillance project.

BACKGROUND AND OBJECTIVES:Chronic kidney disease (CKD) is a significant public health problem whose diagnosis and staging relies upon GFR-estimating equations, including the new CKD-EPI equation. CKD-EPI demonstrated superior performance compared with the existing MDRD equation but has not been applied to a healthcare system. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS:We identified 53,759 patients with stages 3 to 5 CKD on the basis of either MDRD or CKD-EPI equations using two eGFR values <60 ml/min per 1.73 m² > 90 days apart from an outpatient setting. We compared patient characteristics, presence of related diagnosis codes, and time CKD classification between equations. RESULTS:The number of patients identified with CKD decreased 10% applying CKD-EPI versus MDRD. Changes varied substantially by patient characteristics including a 35% decrease among patients < 60 years and a 10% increase among patients > 90 years. Women, non-African Americans, nondiabetics, and obese patients were less likely to be classified on the basis of CKD-EPI. Time to CKD classification was significantly longer with CKD-EPI among younger patients. 14% of patients identified with CKD on the basis of either estimating equation also had a related ICD-9 diagnosis, ranging from 19% among patients < 60 years to 7% among patients > 90 years. CONCLUSIONS:Consistent with findings in the general population, CKD-EPI resulted in substantial declines in equation-based CKD diagnoses in a large healthcare system. Further research is needed to determine whether widespread use of CKD-EPI with current guidelines could lead to delayed needed care among younger patients or excessive referrals among older patients.

ISSUE: For the 2005-6 influenza season our tertiary care center instituted a mandatory healthcare provider (HCP) influenza vaccination self-reporting and declination program utilizing the intranet. HCP vaccination rates increased from 38% to 55% with an 89% participation rate. Our goal for the 2006-7 season was to maintain or exceed participation and vaccination rates and offer the program to other hospitals within our healthcare system.

Background: The Advisory Committee on Immunization Practices and the Healthcare Infection Control Practices Advisory Committee recommend health care personnel (HCP) influenza vaccination to prevent transmission to patients. Recommendations include documenting declination and providing feedback of rates. We report the use of the intranet to achieve recommendations with mandatory participation of 20,170 HCP in an 1100-bed hospital.Methods: Employees were required to log onto the intranet and select "vaccine received," "contraindicated," or "declined." Declining employees automatically received a screen with education about vaccination. A Microsoft Structured Query Language database was created and linked to a Human Resource database. Administrators were provided Feedback on participation rates. Employees were notified of the program, via letter. Reminders were provided through managers and newsletters.Results: Eighty-nine percent (17,998/20,170) accessed the intranet. Fifty-five percent (11,068) indicated "vaccine received" versus 38% in 2004-2005 (P <.000001), 31% (6300) "declined," and 3% (630) had "contraindications." Unit rates ranged from 24% to 91%.Conclusion: The intranet provides a tool for measuring and reporting participation, declination, and vaccination rates. The intranet and a mandatory participation program were associated with an increase in rates. Low rates in HCP with access to, and education about, vaccine may impact consideration of a mandatory vaccination program.

ISSUE: The Advisory Committee on Immunization Practices (ACIP) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) emphasize HCW vaccination against influenza to prevent disease and transmission to patients. Despite education, incentives and easy access to vaccine our influenza vaccine coverage rate for nearly 20,000 HCWs was 38% in 2004. Because mandatory vaccination was met with resistance due to the perception of coercion, we opted for a strategy of mandatory participation with documentation of declination using the intranet as a tool. PROJECT: To establish an intranet web site where employees were required to document participation, declination or vaccination. The site was accessible on all computers and work stations. Employees logged on using their identification number and selected vaccine received, vaccine contraindicated or vaccine declined. Declining employees automatically received education about vaccination. A Microsoft® Structured Query Language database was created and linked to a Human Resource database. Administrators were provided feedback on participation rates. The site provided information about where to obtain vaccine, and a place to ask questions linked by e-mail to an Infection Control Practitioner for prompt response. Employees were notified of the program via letter. Reminders were provided through managers and newsletters. Vaccination rates were not provided to managers or administrators. The site was activated October 17, 2005. RESULTS: As of December 1, 2005, 79% of employees (16,138 / 20,361) participated by accessing the intranet: 50% (10,291) indicated vaccine received; 25.9% (5269) declined; 2.8% (578) declined based on contraindications. Self-reported vaccination included 50% of the Division of Medicine and 45% of the Division of Nursing. Declination was 21% and 30% respectively. Departmental data is available for all patient care locations. There were few complaints as employees understood vaccination data was confidential. LESSONS LEARNED: The intranet provided an inexpensive tool for measuring and timely reporting of HCW participation, declination and vaccination rates. Data management was accomplished without significant expense and cumbersome paperwork. The site provided education to large numbers of employees which may have influenced the increase in the vaccination rate. Real time monitoring by location or occupation allows for targeting interventions where rates are low. Detailed departmental data allows for planning future targeted educational programs. The same tool can be used to document other programs such as fit-testing and TB screening. ISSUE: The Advisory Committee on Immunization Practices (ACIP) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) emphasize HCW vaccination against influenza to prevent disease and transmission to patients. Despite education, incentives and easy access to vaccine our influenza vaccine coverage rate for nearly 20,000 HCWs was 38% in 2004. Because mandatory vaccination was met with resistance due to the perception of coercion, we opted for a strategy of mandatory participation with documentation of declination using the intranet as a tool. PROJECT: To establish an intranet web site where employees were required to document participation, declination or vaccination. The site was accessible on all computers and work stations. Employees logged on using their identification number and selected vaccine received, vaccine contraindicated or vaccine declined. Declining employees automatically received education about vaccination. A Microsoft® Structured Query Language database was created and linked to a Human Resource database. Administrators were provided feedback on participation rates. The site provided information about where to obtain vaccine, and a place to ask questions linked by e-mail to an Infection Control Practitioner for prompt response. Employees were notified of the program via letter. Reminders were provided through managers and newsletters. Vaccination rates were not provided to managers or administrators. The site was activated October 17, 2005. RESULTS: As of December 1, 2005, 79% of employees (16,138 / 20,361) participated by accessing the intranet: 50% (10,291) indicated vaccine received; 25.9% (5269) declined; 2.8% (578) declined based on contraindications. Self-reported vaccination included 50% of the Division of Medicine and 45% of the Division of Nursing. Declination was 21% and 30% respectively. Departmental data is available for all patient care locations. There were few complaints as employees understood vaccination data was confidential. LESSONS LEARNED: The intranet provided an inexpensive tool for measuring and timely reporting of HCW participation, declination and vaccination rates. Data management was accomplished without significant expense and cumbersome paperwork. The site provided education to large numbers of employees which may have influenced the increase in the vaccination rate. Real time monitoring by location or occupation allows for targeting interventions where rates are low. Detailed departmental data allows for planning future targeted educational programs. The same tool can be used to document other programs such as fit-testing and TB screening.

BACKGROUND: Hospital Intranets have been there for a long time but they fail to offer collaborative tools required to manage complex information needs of modern hospitals. Microsoft® Windows® SharePointTM Services (WSS) and Oracle Content services are collaboration environments that enable teams of workers to more easily access and share information than with traditional file servers. WSS is viewed as a tool only suitable for the corporate environment. However, the tool is much more flexible and can be leveraged by academic medical community to help address clinical, research and educational needs. SETTING: Cleveland Clinic Foundation, a tertiary care academic hospital has been utilizing the WSS since 2002. It was originally deployed as an alternative for a project team to share documents without the limitations of a shared drive on computer network. SOLUTION: In this paper, we describe our experience in developing novel clinical, research and educational applications created from WSS and its Web Parts. The details of usability and evaluation results will be presented at the poster session. As a survey tool: Among the many features that WSS offers, is a survey tool. The use of Active Directory at our Institute allows for accesing the full range of SharePoint services, including group mailing lists. This obviates the need for individual emails since surveys can be send in group to housestaff, faculty, nurses for 360 degree evaluations. As a Learning Management System: We have customized WSS to serve as a low-cost learning management system. This has been possible because WSS has built-in support for providing secure access based on user roles ( teacher, student, admin etc.), search of repository of learning materials, announcements, news, task lists, discussion groups and calendar applications. These key applications can be integrated with digital dashboards and Web parts, to create portals with personalised content for students, teachers, and administrators. As a web-based patient signout system: By customizing the “List View” Web Parts, we have been able to develop a web-based patient signout system for Internal Medicine Department. This application has become a part of routine workflow for clinicians, incurring an average of 13,000 total hits/ month. Use of active directory, role-based access and custom programming code has allowed us to address many confidentiality and security issues. As a Research Project Portal: We have successfully leveraged WSS for collaborative grant write-ups. Document management facilities help keep track of version control, and publishing major revisions. Project and grant submission deadlines can be displayed in the calendar and notifications of any additions, modifications or deletions of document can be immediately emailed to the key investigators. Further, rolebased access allows for complete acceess to principle investigator while limiting access of confidential information ( budgets etc.) to other personnel. The portal has been averaging around 330 hits/ month with peaks on manuscript submission days. As a Human Resource (HR) solution: We have developed and hosted a series of self-service forms such as travel expense report, check request form, application for meeting attendance etc. SharePoint site also provides free customized application templates for vacation schedule management, change management, employee timesheet, help desk dashboard and many others. Other uses: An internet search on SharePoint based health care applications reveals that WSS has also been utlilized as an information-gathering program for Patient Documentation Record. Currently, we are also exploring the use of WSS and InfoPath as an electronic data collection tool to support clinical trials at the point of care. CONCLUSIONS: Our experience with Sharepoint Portal suggests that it is a very flexible solution that can be successfully harnessed by academic medical community. Furthermore, since many hospitals have already invested into WSS for operational needs, leveraging WSS for academic needs will provide an incremental value to the hospitals without any added cost.

Cancer PracticeVolume 10, Issue 3 p. 167-169 Using International Web Sites as a Cancer Resource John Sharp mssa , John Sharp mssa John W. Sharp, MSSA, Web Administrator, Cleveland Clinic, Cleveland, Ohio.Search for more papers by this authorPenny Wright bsc, msc, Penny Wright bsc, msc 2 Penny Wright, BSc, MSc, Senior Scientific Officer, ICRF Cancer Medicine Research Unit, St James University Hospital, Leeds, UK.Search for more papers by this author John Sharp mssa , John Sharp mssa John W. Sharp, MSSA, Web Administrator, Cleveland Clinic, Cleveland, Ohio.Search for more papers by this authorPenny Wright bsc, msc, Penny Wright bsc, msc 2 Penny Wright, BSc, MSc, Senior Scientific Officer, ICRF Cancer Medicine Research Unit, St James University Hospital, Leeds, UK.Search for more papers by this author First published: 30 April 2002 https://doi.org/10.1046/j.1523-5394.2002.103005.xCitations: 1 Department Editors: Marie M. Lauria, MSW, CCSW; Victoria Mock, DNSc, RN, AOCN; and Marion E. Morra, MA, ScD. Queries and contributions for Patient Resources may be sent to the Department Editors at Cancer Practice, American Cancer Society, 1180 Avenue of the Americas, New York, NY 10036. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat Citing Literature Volume10, Issue3May 2002Pages 167-169 RelatedInformation