Background: Healthcare Informatics leaders are the bridge between the information systems and clinical departments. The role has grown to where Health Informatics leaders analyze, design, develop, implement, and evaluate information and communication systems that enhance individual and population health outcomes, improve patient care, and strengthen the clinician-patient relationship. Their role spans across administration, information technology into the clinical realm. Objective: The primary objective of this study was to identify the past, current roles, and responsibilities of Health Informatics leaders while the secondary outcome was to identify the future trends in the responsibilities and roles. Methods: A thirteen-question survey was emailed to recipients through listservs. Results: Respondents cited their roles have evolve in respect to EMR to improve patient outcome and efficiency, overseeing compliance with federal and state regulations, design and customization of information technology systems, quality improvement management, healthcare data analytics (machine learning and artificial intelligence), population health management. Conclusion: The role of CMIO and healthcare informatics leaders have begun to be distinctly delineated, and their positions have had a tremendous impact on the integration of health information technology in healthcare. The role of the CMIO will continue to evolve as technology changes.

The validity of adjusting dialysate bicarbonate based on pre‐hemodialysis (HD) serum bicarbonate is unclear. There are no studies of the impact of dialysate sodium on blood pH.

Healthcare ransomware attacks refer to a specific set of cyber-attacks perpetrated against healthcare institutions where malicious software infects the computer systems of a healthcare organization preventing members of the organization from accessing data unless a ransom is paid. This malware is often inadvertently introduced into systems because of intrusion methods such as phishing, where a user opens a file in a seemingly benign message giving the malware access. These attacks have the potential to significantly disrupt patient care, put patient safety at risk, and can prove extremely costly to healthcare institutions.

OBJECTIVE:This study aimed to develop an institutional approach for defining data migration based on participatory design principles.METHODS:We outline a collaborative approach to define data migration as part of an electronic health record (EHR) transition at an urban hospital with 20 ambulatory clinics, based on participatory design. We developed an institution-specific list of data for migration based on physician end-user feedback. In this paper, we review the project planning phases, multidisciplinary governance, and methods used.RESULTS:Detailed data migration feedback was obtained from 90% of participants. Depending on the specialty, requests for historical laboratory values ranged from 2 to as many as 145 unique laboratory types. Lookback periods requested by physicians varied and were ultimately assigned to provide the most clinical data. This clinical information was then combined to synthesize an overall proposed data migration request on behalf of the institution.CONCLUSION:Institutions undergoing an EHR transition should actively involve physician end-users and key stakeholders. Physician feedback is vital for developing a clinically relevant EHR environment but is often difficult to obtain. Challenges include physician time constraints and overall knowledge about health information technology. This study demonstrates how a participatory design can serve to improve the clinical end-user's understanding of the technical aspects of an EHR implementation, as well as enhance the outcomes of such projects.

Shortened red blood cell (RBC) lifespan is one of the major factors contributing to anemia in end-stage renal disease (ESRD) patients and should be taken into account in anemia management protocols. In this study, we aimed to estimate RBC lifespan and the source of between-subject variability in ESRD patients. The resulting individual parameters (empirical Bayes estimates) were used to predict hemoglobin concentrations 2 weeks in advance. The reticulocyte-based estimation of RBC lifespan (REBEL) and the population modeling of RBC count data were used. A total of 120 blood samples collected biweekly over 10 weeks in 24 patients receiving maintenance doses of recombinant human erythropoietin (rHuEPO) subcutaneously were included in this analysis. Typical RBC lifespan was estimated to be 63.3 days. RBC lifespan was found to increase with erythroferrone, a recently identified hormone participating in iron metabolism. Approximately, a 10% increase in plasma erythroferrone was associated with a 5% increase in RBC lifespan. In addition, RBC lifespan was 18.7% shorter in females compared with males. Out of 24 subjects, 16 had hemoglobin concentrations predicted within 95% prediction intervals. The median absolute prediction error was 15.9% (interquartile range, 9.5 to 24.7%). We demonstrated that REBEL coupled with the population modeling technique can be used effectively to estimate RBC lifespan. Then, individual parameters can be used to predict future hemoglobin concentrations in ESRD patients.

The ability to control dosage regimens of erythropoiesis‐stimulating agents (ESAs) to maintain a desired hemoglobin (HGB) target is still elusive. We utilized a Bayesian approach and informative priors to characterize HGB profiles, using simulated drug concentrations, in patients with end‐stage renal disease receiving maintenance doses of epoetin alfa. We also demonstrated an adaptive Bayesian method, applied to individual patients, to improve the accuracy of HGB predictions over time. The results showed that sparse HGB data from daily clinical practice were characterized successfully. The adaptive Bayesian method effectively improved the accuracy of HGB predictions by updating the individual model with new data accounting for within‐subject changes over time. The Bayesian approach presented leverages existing knowledge of the model parameters and has a potential utility in clinical practice to individualize dosage regimens of epoetin alfa and ESAs to achieve target HGB. Further studies are warranted to develop an application for practical use.

Abstract The number of people with End Stage Renal Disease (ESRD) who need dialysis treatment has increased sharply among adults age 75+. Older adults on dialysis have lower rates of advance care planning and higher treatment intensity, hospitalization and intensive care than people other chronic illnesses. Comprehensive care of older adults with ESRD includes advance care planning that addresses goals of care and not just specific medical treatments. The purpose of this study was to explore the nature of symptom burden and advance care planning in dialysis patients. The study design was exploratory, descriptive and cross-sectional. Quantitative and qualitative data were collected during in-person chairside interviews with people having dialysis treatments. Categorical questions focused on demographics and advance directives. The Dialysis Symptom Inventory was used to measure symptom burden. Open-ended questions addressed the trajectory of illness and goals of care. Thirty-five interviews were conducted. Participants’ Mage=55.8 years (range 27-84); 51 % were >60. A distinctive pattern of difference by age emerged. Participants >60 demonstrated greater multimorbidity and lower symptom burden (MDSI=30.13; Range 11-63) compared with those <60 (MDSI=36.31; Range 3-78). Goals of care also varied with age. Older adults’ goals were: (1) Functional (e.g. to walk better, drive); and (2) Existential (e.g. maintaining, surviving, enjoying). Goals of participants <60 were: (1) Transplantation; and (2) Engagement (e.g. work, school, travel). The results suggest that the illness experience and goals are influenced by age and multimorbidity. Implications: ESRD-specific advance care planning conversations with a focus on goals of care are important.

Background: The etiology of sudden cardiac death in patients with end-stage renal disease (ESRD) on hemodialysis (HD) is largely unknown, though there is evidence to suggest that metabolic alkalosis induced by HD with a high-bicarbonate dialysate/prescription may play a role. Methods: We investigated the effects of metabolic alkalosis induced by HD with an acetate-containing bicarbonate-buffered dialysate on frequency of ventricular arrhythmia in 47 patients with ESRD on chronic HD using 48-h Holter monitoring in 3 phases: intra-HD, post-HD day 1, and post-HD day 2. Serum levels of bicarbonate, calcium, and potassium along with hemodynamics were measured pre-HD, post-HD, 20-h post-HD, and 44-h post-HD. Correlations were performed to verify the association between bicarbonate prescription and change in serum bicarbonate levels post-HD and to determine if the HD-induced change in serum bicarbonate level (metabolic alkalosis) had any direct association with ambient ventricular arrhythmia (premature ventricular contractions per hour) or indirect associations with ambient ventricular arrhythmia by affecting electrolytes or hemodynamics that are known to increase the risk of ventricular arrhythmia. Results: Mean pre-HD serum bicarbonate level was 21.3 mEq/L. Dialysate bicarbonate prescription (mean of 36.4 mEq/L) correlated with changes in serum bicarbonate levels immediately post-HD 26.7 mEq/L (r = 0.46, p < 0.01), 20-h post-HD 25.2 mEq/L (r = 0.38), and 44-h post-HD 23.2 mEq/L (r = 0.35, p = 0.01). No statistically significant correlations were found between the post-HD change in serum bicarbonate levels (metabolic alkalosis) with ambient ventricular arrhythmia, changes in serum calcium, potassium, or hemodynamics in any phase. Conclusions: High-bicarbonate dialysate prescription is associated with metabolic alkalosis following the HD procedure. A mild metabolic alkalosis induced by HD with an acetate-containing bicarbonate-buffered dialysate solution had no direct association with ambient ventricular arrhythmia on Holter monitoring and was not associated with changes in hemodynamics or changes in serum total calcium or potassium levels. This study helps to provide guidance for the safe use of high bicarbonate dialysate/prescription in patients with ESRD on HD.

Patient portal and personal health record adoption and usage rates have been suboptimal. A systematic review of the literature was performed to capture all published studies that specifically addressed barriers, facilitators, and solutions to optimal patient portal and personal health record enrollment and use. Consistent themes emerged from the review. Patient attitudes were critical as either barrier or facilitator. Institutional buy-in, information technology support, and aggressive tailored marketing were important facilitators. Interface redesign was a popular solution. Quantitative studies identified many barriers to optimal patient portal and personal health record enrollment and use, and qualitative and mixed methods research revealed thoughtful explanations for why they existed. Our study demonstrated the value of qualitative and mixed research methodologies in understanding the adoption of consumer health technologies. Results from the systematic review should be used to guide the design and implementation of future patient portals and personal health records, and ultimately, close the digital divide.

Erythropoiesis-stimulating agents (eg, epoetin alfa) are the primary treatment for anemia in patients with end-stage renal disease. Hemoglobin variability in and out of a narrow target range is common and associated with higher morbidity and mortality risk. More robust erythropoiesis-stimulating agent response metrics are needed to define optimal dosing and their association with clinical outcomes. In this cross-sectional, single-center, retrospective study, 49 patients with end-stage renal disease on hemodialysis were followed over 12 months. To quantify hemoglobin deviations outside the target range (10-12 g/dL), the area under the curve of hemoglobin versus time over a 12-month period (AUC-HGB) was calculated using the trapezoidal rule. Patients were categorized into 4 responder groups based on AUC-HGB quartiles. Comparative analyses of demographic and clinical characteristics between responder groups were performed. Correlations between AUC-HGB, erythropoietin resistance index, and time within therapeutic range were calculated. There were no significant differences in laboratory and dialysis parameters between responder groups except hemoglobin concentration and epoetin alfa dose. There was a negative correlation between AUC-HGB and time within therapeutic range (r = -.92; P < .001) and hemoglobin concentration (r = -.85; P < .01), indicating internal validity of the metric. There was a positive correlation between AUC-HGB and erythropoietin resistance index (r = .70; P < .001) indicating external validity. The poor response group received a higher median epoetin alfa dose (160 U/kg/week) compared to the excellent response group (68.8 U/kg/week; P < .001) with a similar number of dose changes between the groups. AUC-HGB is a valid marker of epoetin alfa response and should be considered in future analyses of larger populations.

Purpose: The Health Insurance Portability and Accountability Act does not prevent patient portals or personal health records from sharing access to information with adolescents and their personal representatives. Yet huge variations exist in the type and amount of information made available to this specific age demographic. A notable barrier in the pediatric community is the inconsistent availability of meaningful information access for adolescent patients …

Fresenius Medical Care's NaturaLyte dialysate has been associated with increased risk of sudden cardiac death by causing metabolic alkalosis from its acetate content based on retrospective data using pre‐dialysis bicarbonate levels only. The study objective was to measure inter/intra‐dialytic changes in serum bicarbonate and degree of alkalosis conferred by varying concentrations of NaturaLyte bicarbonate dialysate. Thirty‐nine hemodialysis patients were divided into four groups based on prescribed bicarbonate dialysate concentrations; Group 1 (N = 9): 30–32 mEq/L, Group 2 (N = 5): 33–34 mEq/L, Group 3 (N = 10): 35–36 mEq/L, Group 4 (N = 15): 37–40 mEq/L. Serial (pre‐dialysis, immediate post‐dialysis, 2 h post‐dialysis, and 68 h post‐dialysis) bicarbonate levels were measured. Mean pre‐dialysis serum bicarbonate levels (representing 44 h post‐dialysis levels) in all four groups were not statistically different. Pre‐dialysis and 68 h post‐dialysis bicarbonate levels in each group were also not significantly different. However, immediate post‐dialysis and 2 h post‐dialysis bicarbonate levels were significantly increased in all four groups proportional to dialysate dose. There was statistically significant inter‐group bicarbonate level difference (P < 0.05) except between the first and second (P = 0.43) and second and third (P = 0.07) groups in the immediate post‐dialysis period. Similar results were obtained for the 2 h post‐dialysis period. High bicarbonate dialysate causes large and rapid fluctuations in serum bicarbonate levels during the intra/inter‐dialytic period, which returns to baseline within 44 to 68 h after dialysis. This refutes the necessity to correct pre‐dialysis acidosis with high bicarbonate dialysate since rapid equilibration is likely to occur and unnecessarily exposes patients to large shifts in their acid base balance.

Renin–angiotensin system (RAS) activation increases angiotensin II production stimulating profibrotic factors, especially in the setting of chronic kidney disease. Nephrogenic systemic fibrosis (NSF) has been associated with gadolinium (Gd) exposure and renal failure. RAS involvement in NSF is unclear compared to transforming growth factor beta and Smad. RenTag mice were chosen to investigate the role of RAS in NSF-like dermal fibrosis because they demonstrated dermal fibrosis at birth, perturbations of RAS in subcutaneous tissue, and renal failure within 4 weeks of age.

Renal transplantation (Tx) improves mortality and morbidity but is limited by availability of suitable organs. Clinical and economic impact of a Tx program for end-stage renal disease (ESRD) prisoners was evaluated. Wait list time and patient and organ survival rates were assessed. Twelve of the 104 ESRD prisoners at a prison dialysis unit were activated; 9 transplanted, 2 released active on the United Network for Organ Sharing list, and 1 died after listing. Kidneys from antibody-positive hepatitis C (HepC) donors were given to consenting HepC antibody-positive recipients. The average waiting period was 6.6 months for HepC-positive kidney recipients and 49.6 months for others. Compared with costs of continuing dialysis, Tx resulted in substantial savings. Patients with HepC experienced good graft and survival rates when given grafts from HepC donors, suggesting that transplantation is a viable, cost-effective option for the incarcerated patient with ESRD including those who have chronic HepC infection.

The specialty of Nephrology, by virtue of its relationship with the dialysis procedure, is highly vulnerable to litigation. As is the case with all nephrologists, a dialysis unit medical director is not immune to medical malpractice suits, and can be held liable for any act of perceived or potential harm to any dialysis patient, regardless of the director's level of involvement. The medical director, per the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation, accepts the responsibilities, accountability, and consequent legal liabilities of the quality of the medical care provided to every dialysis patient in the unit. This review is a synopsis of lawsuits filed against medical directors of dialysis units in the past forty years. Six categories of legal actions were noted; medical malpractice, fraudulent claims, self-referral and Stark Law, discrimination, negligence, and violation of patient autonomy and dignity.