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McNamara M, McLamore Q, Meade N, Olgun M, Robinson H, Alstott A. A thematic analysis of disinformation in gender-affirming healthcare bans in the United States. Soc Sci Med 2024; 351:116943. [PMID: 38759383 DOI: 10.1016/j.socscimed.2024.116943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 04/18/2024] [Accepted: 05/03/2024] [Indexed: 05/19/2024]
Abstract
CONTEXT Bans on gender-affirming care (GAC) for transgender and gender-expansive (TGE) people are grounded in scientific disinformation and have been challenged in American courts. METHODS Five legal filings by state officials in defense of GAC restriction from initial litigation were analyzed using reflexive thematic analysis. Themes and subthemes of disinformation were identified after review and analysis of these filings. FINDINGS Five themes of disinformation emerged: False and misleading claims about (1) gender dysphoria and gender identity, (2) the evidence regarding GAC, (3) standard practice of GAC, (4) the safety of GAC, and finally, (5) rejection of medical authority. These themes were well represented across the analyzed documents. CONCLUSIONS The five disinformation themes and subthemes have been noted in lower courts, but have seen some purchase in appellate courts, suggesting that medical disinformation in law may have far-reaching consequences for medical policy.
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Affiliation(s)
| | | | - Nicolas Meade
- Yale School of Medicine, United States; University of Missouri at Columbia, United States
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2
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Chung RJ, Lee JB, Hackell JM, Alderman EM. Confidentiality in the Care of Adolescents: Technical Report. Pediatrics 2024; 153:e2024066327. [PMID: 38646698 DOI: 10.1542/peds.2024-066327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 04/23/2024] Open
Abstract
Confidentiality is a foundational element of high-quality, accessible, and equitable health care. Despite strong grounding in federal and state laws, professional guidelines, and ethical standards, health care professionals and adolescent patients face a range of complexities and barriers to seeking and providing confidential care to adolescents across different settings and circumstances. The dynamic needs of adolescents, the oftentimes competing interests of key stakeholders, the rapidly evolving technological context of care, and variable health care billing and claims requirements are all important considerations in understanding how to optimize care to focus on and meet the needs of the adolescent patient. The following assessment of the evolving evidence base offers a view of the current state and best practices while pointing to numerous unmet needs and opportunities for improvement in the care experiences of youth as well as their health outcomes.
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Affiliation(s)
- Richard J Chung
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Janet B Lee
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Jesse M Hackell
- Department of Pediatrics, New York Medical College, Valhalla, New York
| | - Elizabeth M Alderman
- Division of Adolescent Medicine, Department of Pediatrics, Albert Einstein College of Medicine and The Children's Hospital at Montefiore, Bronx, New York
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3
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The ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder. J Addict Med 2024; 18:1-56. [PMID: 38669101 DOI: 10.1097/ADM.0000000000001299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
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4
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Eniola K, Brown C, Pray M, Foster KE, Richter S, Parker M, Carvajal DN. Assessing the Knowledge and Comfort Level of US Family Medicine Residents Regarding Consenting and Confidentiality in Adolescent Health Care. South Med J 2024; 117:272-278. [PMID: 38701849 PMCID: PMC11073802 DOI: 10.14423/smj.0000000000001683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
OBJECTIVES Organizations recommend providing confidential adolescent health care to reduce the consequences of high-risk health behaviors such as substance use, unhealthy eating patterns, and high-risk sexual behaviors. Family physicians are uniquely positioned to provide confidential counseling and care to this vulnerable population but must be trained to provide such care. This study describes the impact of formal and informal training on the knowledge of and comfort level in providing confidential adolescent healthcare among a sample of US Family Medicine residents. METHODS Electronic surveys were distributed to all Family Medicine residents throughout the United States. We used descriptive statistics and χ2 analysis where appropriate to determine the association between resident-reported receipt of training, confidence, and frequency in providing confidential adolescent health care. RESULTS A total of 714 Family Medicine residents completed the survey. The majority reported no formal training in residency (50.3%). The receipt of formal and informal training in both medical school and residency was associated with a greater degree of comfort in providing confidential adolescent care and a higher likelihood of providing confidential time alone. Those reporting formal training were more likely to always provide confidential care (P = 0.001). CONCLUSIONS Training focused on confidential adolescent health care in medical school or residency was associated with a greater degree of comfort and a higher likelihood of providing confidential adolescent health care.
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Affiliation(s)
| | - Carina Brown
- Cone Health Family Medicine, Greensboro, North Carolina
| | - Margaret Pray
- Cone Health Family Medicine, Greensboro, North Carolina
| | - Krys E. Foster
- Department of Family & Community Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Scott Richter
- University of North Carolina at Greensboro, Greensboro
| | | | - Diana N. Carvajal
- Department of Family and Community Medicine, University of Maryland School of Medicine, Baltimore
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Chung RJ, Lee JB, Hackell JM, Alderman EM. Confidentiality in the Care of Adolescents: Policy Statement. Pediatrics 2024; 153:e2024066326. [PMID: 38646690 DOI: 10.1542/peds.2024-066326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 04/23/2024] Open
Abstract
Confidentiality is an essential component of high-quality health care for adolescents and young adults and can have an impact on the health care experiences and health outcomes of youth. Federal and state laws, professional guidelines, and ethical standards provide a core framework for guidance in the implementation of confidentiality protections in clinical practice. This policy statement provides recommendations for pediatricians and other pediatric health care professionals, clinics, health systems, payers, and electronic health record developers to optimize confidentiality practices and protections for adolescents and young adults across the spectrum of care.
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Affiliation(s)
- Richard J Chung
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Janet B Lee
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Jesse M Hackell
- Department of Pediatrics, New York Medical College, Valhalla, New York
| | - Elizabeth M Alderman
- Division of Adolescent Medicine, Department of Pediatrics, Albert Einstein College of Medicine and The Children's Hospital at Montefiore, Bronx, New York
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Welsh JW, Dopp AR, Durham RM, Sitar SI, Passetti LL, Hunter SB, Godley MD, Winters KC. Narrative review: Revised Principles and Practice Recommendations for Adolescent Substance Use Treatment and Policy. J Am Acad Child Adolesc Psychiatry 2024:S0890-8567(24)00140-0. [PMID: 38537736 DOI: 10.1016/j.jaac.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/24/2024] [Accepted: 03/18/2024] [Indexed: 04/08/2024]
Abstract
OBJECTIVE In 2014, the U.S. National Institute on Drug Abuse released the "Principles of Adolescent Substance Use Disorder Treatment," summarizing previously established evidence and outlining principles of effective assessment, treatment, and aftercare for substance use disorders (SUD). Winters et al. (2018) updated these principles to be developmentally appropriate for adolescents. This review builds on that formative work and recommends updated adolescent assessment, treatment, and aftercare principles and practices. METHOD The Cochrane, MEDLINE-PubMed, and PsychInfo databases were searched for relevant studies with new data about adolescent substance use services. This article updates the 13 original principles; condenses the 8 original modalities into 5 practices; and highlights implications for public policy approaches, future funding, and research. RESULTS Key recommendations from the principles include integrating care for co-occurring mental health disorders and SUDs, improving service accessibility including through the educational system, maintaining engagement, and addressing tension between agencies when collaborating with other youth service systems. Updates to the treatment practices include adoption of Screening, Brief Intervention and Referral to Treatment (SBIRT), investment in social programs and family involvement in treatment, expanding access to behavioral therapies and medications, increasing funding to harm reduction services, supporting reimbursement for continuing care services, and increasing investment in research. CONCLUSION These revised principles of adolescent assessment, treatment, and aftercare approaches and practices aim to establish guidance and evidence-based practices for treatment providers, while encouraging necessary support from policymakers and funding agencies to improve the standard of care for adolescent SUD services.
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Sisk B, Antes AL, Bereitschaft C, Enloe M, Bourgeois F, DuBois J. Guiding Principles for Adolescent Web-Based Portal Access Policies: Interviews With Informatics Administrators. JMIR Pediatr Parent 2024; 7:e49177. [PMID: 38466976 DOI: 10.2196/49177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 11/17/2023] [Accepted: 02/14/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Web-based patient portals are tools that could support adolescents in managing their health and developing autonomy. However, informatics administrators must navigate competing interests when developing portal access policies for adolescents and their parents. OBJECTIVE We aimed to assess the perspectives of informatics administrators on guiding principles for the development of web-based health care portal access policies in adolescent health care. METHODS We interviewed informatics administrators from US hospitals with ≥50 dedicated pediatric beds. We performed a thematic analysis of guiding principles for developing and implementing adolescent portal access policies. RESULTS We interviewed 65 informatics leaders who represented 63 pediatric hospitals, 58 health care systems, 29 states, and 14,379 pediatric hospital beds. Participants described 9 guiding principles related to three overarching themes: (1) balancing confidentiality and other care needs, (2) balancing simplicity and granularity, and (3) collaborating and advocating. Participants described the central importance of prioritizing the health and safety of the adolescent while also complying with state and federal laws. However, there were differing beliefs about how to prioritize health and safety and what role parents should play in supporting the adolescent's health care. Participants also identified areas where clinicians and institutions can advocate for adolescents, especially with electronic health record vendors and legislators. CONCLUSIONS Informatics administrators provided guiding principles for adolescent portal access policies that aimed to balance the competing needs of adolescent confidentiality and the usefulness of the portal. Portal access policies must prioritize the adolescent's health and safety while complying with state and federal laws. However, institutions must determine how to best enact these principles. Institutions and clinicians should strive for consensus on principles to strengthen advocacy efforts with institutional leadership, electronic health record vendors, and lawmakers.
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Affiliation(s)
- Bryan Sisk
- Bioethics Research Center, Department of Medicine, Washington University School of Medicine, St Louis, MO, United States
- Division of Hematology and Oncology, Department of Pediatrics, Washington University, St Louis, MO, United States
| | - Alison L Antes
- Bioethics Research Center, Department of Medicine, Washington University School of Medicine, St Louis, MO, United States
| | - Christine Bereitschaft
- Division of Hematology and Oncology, Department of Pediatrics, Washington University, St Louis, MO, United States
| | - Madi Enloe
- Division of Hematology and Oncology, Department of Pediatrics, Washington University, St Louis, MO, United States
| | - Fabienne Bourgeois
- Boston Children's Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - James DuBois
- Bioethics Research Center, Department of Medicine, Washington University School of Medicine, St Louis, MO, United States
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8
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Shirazi A, Radgoudarzi N, Brody AL. Adolescent Tobacco/Nicotine Use and the Potential Role of Contingency Management-based Interventions. J Addict Med 2024; 18:97-102. [PMID: 38197859 PMCID: PMC10939979 DOI: 10.1097/adm.0000000000001249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
ABSTRACT The high prevalence of tobacco/nicotine use among youth, including e-cigarettes, is a public health problem in the United States. Early exposure leads to an increased risk of dependence and health consequences in adulthood. We reviewed the literature on current treatment approaches for nicotine/tobacco use in adolescents/young adults and highlighted underexplored areas of treatment research. There are no current Food and Drug Administration-approved medications for treatment of nicotine/tobacco use disorders in adolescents. However, in research settings and on a case-to-case basis, clinical practice medications (including nicotine replacement therapy, bupropion, and varenicline) have been prescribed to this population with consideration of risk-benefit analysis when behavioral treatments are not sufficient to address dependence. Among the nonpharmacological interventions, there is evidence to support the potential for expanded use of contingency management in youth. Neural differences predisposing adolescents to substance use, along with higher attentiveness to value of options in decision making (flexible reward system) may enhance the effectiveness of reward-based approaches for treatment of substance use disorders in this population. The overall high rates of nonresponders across psychosocial and pharmacological treatments highlight the importance of considering novel strategies to improve existing interventions. We suggest that future research be done that considers unique characteristics of today's adolescents, such as high social activism and engagement with digital rewards to tailor contingency management for this age group and assess its effectiveness. Adolescents could potentially benefit from rewards administered through digital media (eg, video games, computer-based apps, and social media influencers).
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Affiliation(s)
- Anaheed Shirazi
- Department of Psychiatry, University of California San Diego, San Diego, CA
| | | | - Arthur L. Brody
- Department of Psychiatry, University of California San Diego, San Diego, CA
- Department of Research, VA San Diego Healthcare System, San Diego, CA
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Voronov A, Jafari M, Zhao L, Soliz M, Hong Q, Pope J, Chern D, Lipman M, Grando A. Pediatric Consent on FHIR. Appl Clin Inform 2024; 15:342-356. [PMID: 38508581 PMCID: PMC11078568 DOI: 10.1055/a-2291-1482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 03/18/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Standardizing and formalizing consent processes and forms can prevent ambiguities, convey a more precise meaning, and support machine interpretation of consent terms. OBJECTIVES Our goal was to introduce a systematic approach to standardizing and digitizing pediatric consent forms, which are complex due to legal requirements for child and legal guardian involvement. METHODS First, we reviewed the consent requirements from the Arizona regulation, and we used 21 pediatric treatment consents from five Arizona health care organizations to propose and evaluate an implementation-agnostic Consent for Treatment Framework. Second, we assessed the adequacy of the Fast Healthcare Interoperability Resources (FHIR) to support the proposed framework. RESULTS The resulting Consent for Treatment Framework supports compliance with the state consent requirements and has been validated with pediatric consent forms. We also demonstrated that the FHIR standard has the required expressiveness to compute the framework's specifications and express the 21 consent forms. CONCLUSION Health care organizations can apply the shared open-source code and FHIR implementation guidelines to standardize the design of machine-interpretable pediatric treatment consent forms. The resulting FHIR-based executable models may support compliance with the law and support interoperability and data sharing.
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Affiliation(s)
- Anton Voronov
- College of Health Solutions, Arizona State University, Phoenix, Arizona, United States
| | - Mohammad Jafari
- College of Health Solutions, Arizona State University, Phoenix, Arizona, United States
| | - Lin Zhao
- HonorHealth, Phoenix, Arizona, United States
| | - Melissa Soliz
- Coppersmith Brockelman PLC, Phoenix, Arizona, United States
| | - Qixuan Hong
- Ira A Fulton School of Engineering, Arizona State University, Phoenix, Arizona, United States
| | - John Pope
- HonorHealth, Phoenix, Arizona, United States
| | | | - Megan Lipman
- Jewish Family and Children's Services, Phoenix, Arizona, United States
| | - Adela Grando
- College of Health Solutions, Arizona State University, Phoenix, Arizona, United States
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10
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Reilly K, Ebersole A. Confidentiality and privacy considerations for adolescents receiving contraceptive health services via telemedicine: A narrative review. Womens Health (Lond) 2024; 20:17455057241233126. [PMID: 38424665 PMCID: PMC10908226 DOI: 10.1177/17455057241233126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 12/21/2023] [Accepted: 01/25/2024] [Indexed: 03/02/2024]
Abstract
Confidential medical care for adolescent patients is essential as they are likely to forgo needed care if privacy cannot be maintained. The use of telemedicine for adolescent health has rapidly expanded due to the COVID-19 pandemic and can increase access to important services like reproductive care; however, it has raised challenges for providers, patients, and their parents/guardians related to confidentiality and privacy. Health care providers are often uncertain about the laws and regulations that govern confidential services including the 21st Century Cures Act. Through a narrative review of studies on confidentiality and telemedicine, this article seeks to summarize the available evidence and provide recommendations on maintaining privacy during virtual encounters and identify current best practices for prescribing contraception via telemedicine.
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Affiliation(s)
| | - Ashley Ebersole
- The Ohio State University College of Medicine, Division of Adolescent Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
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11
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Sprackling CM, Kieren MQ, Nacht CL, Moreno MA, Wooldridge A, Kelly MM. Adolescent Access to Clinicians' Notes: Adolescent, Parent, and Clinician Perspectives. J Adolesc Health 2024; 74:155-160. [PMID: 37831050 PMCID: PMC10842681 DOI: 10.1016/j.jadohealth.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 08/02/2023] [Accepted: 08/04/2023] [Indexed: 10/14/2023]
Abstract
PURPOSE In 2021, federal guidelines mandated that health-care organizations share clinicians' notes with patients to increase information transparency. While findings indicate advantages for adult patients, less is known about note-sharing from the viewpoint of adolescents. This study aims to identify adolescent, parent, and clinician perspectives on the anticipated benefits and concerns of giving adolescents access to clinicians' notes and strategies to support note-sharing in this population. METHODS We conducted six focus groups with adolescents, parents, and clinicians at a children's hospital from May to October 2021. A semistructured facilitator guide captured participant perspectives of note-sharing benefits, concerns, and strategies. Two researchers independently coded and analyzed transcript data using thematic analysis; a third researcher reconciled discrepancies. RESULTS 38 stakeholders (17 adolescents, 10 parents, and 11 clinicians) described four benefits, three concerns, and four implementation strategies regarding adolescent note-sharing. Potential benefits included adolescents using notes to remember and reinforce the visit, gaining knowledge about their health, strengthening the adolescent-clinician relationship, and increasing agency in health care decisions. Concerns included notes leading to a breach in confidentiality, causing negative emotions, and becoming less useful for clinicians. Strategies included making note-sharing more secure, optimizing note layout and content, setting clear expectations, and having a portion of the note for clinician use only. DISCUSSION Stakeholders suggest multiple strategies to optimize the implementation of note-sharing to support adolescent patients, parents, and clinicians as hospitals work to comply with federal regulations. These strategies may reinforce the potential benefits and mitigate the challenges of sharing notes with adolescent patients.
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Affiliation(s)
- Carley M Sprackling
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Madeline Q Kieren
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Carrie L Nacht
- School of Public Health, San Diego State University, San Diego, California
| | - Megan A Moreno
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Abigail Wooldridge
- Department of Industrial and Enterprise Systems Engineering, University of Illinois Urbana-Champaign, Champaign, Illinois
| | - Michelle M Kelly
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
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12
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Smith WR, Appelbaum PS, Lebowitz MS, Gülöksüz S, Calkins ME, Kohler CG, Gur RE, Barzilay R. The Ethics of Risk Prediction for Psychosis and Suicide Attempt in Youth Mental Health. J Pediatr 2023; 263:113583. [PMID: 37353146 PMCID: PMC10828819 DOI: 10.1016/j.jpeds.2023.113583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 06/01/2023] [Accepted: 06/16/2023] [Indexed: 06/25/2023]
Abstract
OBJECTIVE To identify potential clinical utility of polygenic risk scores (PRS) and exposomic risk scores (ERS) for psychosis and suicide attempt in youth and assess the ethical implications of these tools. STUDY DESIGN We conducted a narrative literature review of emerging findings on PRS and ERS for suicide and psychosis as well as a literature review on the ethics of PRS. We discuss the ethical implications of the emerging findings for the clinical potential of PRS and ERS. RESULTS Emerging evidence suggests that PRS and ERS may offer clinical utility in the relatively near future but that this utility will be limited to specific, narrow clinical questions, in contrast to the suggestion that population-level screening will have sweeping impact. Combining PRS and ERS might optimize prediction. This clinical utility would change the risk-benefit balance of PRS, and further empirical assessment of proposed risks would be necessary. Some concerns for PRS, such as those about counseling, privacy, and inequities, apply to ERS. ERS raise distinct ethical challenges as well, including some that involve informed consent and direct-to-consumer advertising. Both raise questions about the ethics of machine-learning/artificial intelligence approaches. CONCLUSIONS Predictive analytics using PRS and ERS may soon play a role in youth mental health settings. Our findings help educate clinicians about potential capabilities, limitations, and ethical implications of these tools. We suggest that a broader discussion with the public is needed to avoid overenthusiasm and determine regulations and guidelines for use of predictive scores.
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Affiliation(s)
- William R Smith
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
| | - Paul S Appelbaum
- Department of Psychiatry, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY; New York State Psychiatric Institute, New York, NY
| | - Matthew S Lebowitz
- Department of Psychiatry, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY
| | - Sinan Gülöksüz
- Department of Psychiatry, Yale School of Medicine, New Haven, CT; Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Monica E Calkins
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Christian G Kohler
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Raquel E Gur
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Lifespan Brain Institute, Children's Hospital of Philadelphia and Penn Medicine, University of Pennsylvania, Philadelphia, PA; Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Ran Barzilay
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA; Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
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13
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Kamke K, Mullin TM, Goodman KL. Barriers to Seeking Medical Care Among Youth Victims of Sexual Violence. J Adolesc Health 2023; 73:1077-1082. [PMID: 37676193 DOI: 10.1016/j.jadohealth.2023.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 09/08/2023]
Abstract
PURPOSE Youth victims of sexual violence often experience physical health problems but are unlikely to receive medical care. However, victims' reasons for not accessing medical care have been understudied. We examined barriers to seeking medical care among youth victims who contacted the National Sexual Assault Online Hotline. METHODS We used archival data about one-on-one chat sessions with youth victims between June 2018 and February 2020. Hotline staff described victims' reasons for not accessing medical care via an online assessment. We coded and qualitatively examined these reasons using data about 520 victims with physical health concerns who had not received medical care. RESULTS Victims' barriers were rooted in individual beliefs and contextual realities reflected in three categories: (1) perception that medical care was not needed, (2) anticipated consequences of seeking medical care, and (3) inability to physically access medical care. Victims who perceived care as unnecessary did not understand the health implications of abuse or minimized their need for care. Anticipated consequences included privacy and control over disclosure, stigmatization, retaliation from the perpetrator, family disruptions, and retraumatizing medical treatment. Victims unable to physically access care were uncertain how to access care independently, lacked social support, or were prevented from care by the perpetrator. DISCUSSION Medical treatment can ameliorate acute health concerns and increase safety, but youth victims perceived numerous barriers to care. Several barriers implied unintended consequences of child maltreatment policies, including mandatory reporting. Trauma-informed policy and practice are critical for improving victims' access to medical care and other support services.
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Affiliation(s)
- Kristyn Kamke
- Research & Evaluation Team, Department of Victim Services, Rape, Abuse & Incest National Network (RAINN), Washington, D.C..
| | - Tara M Mullin
- Research & Evaluation Team, Department of Victim Services, Rape, Abuse & Incest National Network (RAINN), Washington, D.C
| | - Kimberly L Goodman
- Research & Evaluation Team, Department of Victim Services, Rape, Abuse & Incest National Network (RAINN), Washington, D.C
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14
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Sinha S, Bedgood M, Puttagunta R, Kataria A, Bourgeois F, Lee JA, Vodzak J, Hall E, Levy B, Vawdrey DK. Variation in pediatric and adolescent electronic health data sharing practices under the 21st Century Cures Act. J Am Med Inform Assoc 2023; 30:2021-2027. [PMID: 37643734 PMCID: PMC10654877 DOI: 10.1093/jamia/ocad172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 08/09/2023] [Accepted: 08/15/2023] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVE To describe real-world practices and variation in implementation of the Information Blocking provisions amongst healthcare organizations caring for pediatric patients. MATERIALS AND METHODS An online survey regarding implementation practices was distributed to representatives from 10 participating US healthcare organizations located in 6 different states. The survey was followed by structured interviews conducted through video conference. Information was gathered about implementation practices at each organization, with a focus on patient and proxy portal access to, and segmentation capabilities of, certain data classes listed in the United States Core Data for Interoperability Version 1. RESULTS All organizations had implemented the information blocking provisions at their institution. All organizations utilized different portal account types for proxies and users. All organizations reported the capability of sharing labs, medications, problem lists, imaging, and notes with the parent/guardian of the non-adolescent minor user with differences in how sensitive elements within the data classes were protected. Variability existed in how data was shared with the remaining user types. DISCUSSION Significant variability exists in how organizations have implemented the information blocking rules. Variation in data sharing and data access between institutions can result in privacy breaches and create confusion about completeness of data for patients and families. CONCLUSION Healthcare organizations have utilized varying strategies to comply with the information blocking provisions of the 21st Century Cures Act. Increased clarity from the Office of the National Coordinator for Health Information Technology on minor, adolescent, and caregiver privacy and improved segmentation capabilities from Electronic Health Record vendors is needed.
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Affiliation(s)
- Shikha Sinha
- Department of Informatics, Geisinger Health System, Danville, PA 17821, United States
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, PA 19146, United States
| | - Michael Bedgood
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA 94304, United States
- California Department of Public Health, Coronavirus Science Branch, Richmond, CA 94804, United States
| | - Raghuveer Puttagunta
- Department of Informatics, Geisinger Health System, Danville, PA 17821, United States
- Department of Pediatrics, Geisinger Health System, Danville, PA 17821, United States
| | - Akaash Kataria
- Department of Informatics, Geisinger Health System, Danville, PA 17821, United States
- Department of Pediatrics, Geisinger Health System, Danville, PA 17821, United States
| | - Fabienne Bourgeois
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA 19148, United States
| | - Jennifer A Lee
- Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH 43210, United States
- Divisions of Pediatric Gastroenterology and Clinical Informatics, Hepatology, and Nutrition, Nationwide Children’s Hospital, Columbus, OH 43205, United States
| | - Jennifer Vodzak
- Department of Informatics, Geisinger Health System, Danville, PA 17821, United States
- Department of Pediatrics, Geisinger Health System, Danville, PA 17821, United States
| | - Eric Hall
- Research Institute, Geisinger Health System, Danville, PA 17821, United States
| | - Bruce Levy
- Department of Informatics, Geisinger Health System, Danville, PA 17821, United States
- Geisinger Commonwealth School of Medicine, Scranton, PA 18510, United States
| | - David K Vawdrey
- Department of Informatics, Geisinger Health System, Danville, PA 17821, United States
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15
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Doan TT, DeJonckheere M, Wright DR, Hutton DW, Prosser LA. Preferences and experiences of pediatricians on implementing national guidelines on universal routine screening of adolescents for major depressive disorder: A qualitative study. Compr Psychiatry 2023; 127:152412. [PMID: 37717343 DOI: 10.1016/j.comppsych.2023.152412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 08/07/2023] [Accepted: 08/14/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND To explore the preferences of pediatricians for key factors around the implementation of universal routine screening guidelines for major depressive disorder in adolescent patients in a primary care setting. METHOD Semi-structured qualitative interviews were conducted with U.S. pediatricians. Participants were recruited by convenience sampling and snowball sampling. Qualitive data were summarized using thematic analysis to identify themes relevant to preferences around implementing screening strategies for adolescent patients. Recruitment ended upon reaching thematic saturation when no new themes were revealed. RESULTS Of the 14 participants, 11 identified as female, 3 male, 10 white, and 4 Asian. Top themes among pediatrician participants were around the screening modality (14/14 participants), screening validity (14/14), time barriers (14/14), and confidentiality barriers (12/14). Less frequently mentioned themes by pediatricians were workplace coordination and logistics (7/14), alternative starting ages for screening (7/14), more frequent screenings than annual screenings (3/14), and additional clinical training regarding depression diagnosis and treatment (2/14). LIMITATIONS Pool of interviewed participants was limited by diversity in terms of geography, race/ethnicity, or practice settings. CONCLUSIONS To promote the uptake of universal routine screening of adolescent major depression, pediatricians expressed it was important to address key implementation factors regarding the screening modality, screening validity, time constraints, and confidential care concerns in a primary care delivery context. Findings could be used to inform the development of implementation strategies to facilitate depression screening in primary care. Future research is needed to quantitively assess decisions and tradeoffs that pediatricians make when implementing universal screening to support adolescent mental health.
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Affiliation(s)
- Tran T Doan
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Melissa DeJonckheere
- Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Davene R Wright
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - David W Hutton
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Lisa A Prosser
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA; Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, University of Michigan, Ann Arbor, MI, USA
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16
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Singh S, Drabiak K. Parental Rights Laws and the Impact on Mental Health Services and Counseling for Adolescents. J Sch Health 2023; 93:1049-1054. [PMID: 37254626 DOI: 10.1111/josh.13356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/03/2023] [Accepted: 05/21/2023] [Indexed: 06/01/2023]
Affiliation(s)
- Sarina Singh
- Morsani College of Medicine, University of South Florida, Tampa, FL
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17
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de Londras F, Cleeve A, Rodriguez MI, Farrell A, Furgalska M, Lavelanet AF. The impact of third-party authorization requirements on abortion-related outcomes: a synthesis of legal and health evidence. BMC Public Health 2023; 23:2065. [PMID: 37872513 PMCID: PMC10591342 DOI: 10.1186/s12889-023-16307-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 07/13/2023] [Indexed: 10/25/2023] Open
Abstract
OBJECTIVES This review synthesizes legal and health evidence to demonstrate the health and human rights impacts of third-party authorization requirements (TPAs) on abortion seekers. RESULTS The synthesized evidence substantiates the pre-existing position in international human rights law that requirements that abortion be authorized by third parties like parents, spouses, committees, and courts create barriers to abortion, should not be introduced at all, or should be repealed where they exist. CONCLUSIONS The review establishes that rights-based regulation of abortion should not impose TPAs in any circumstances. Instead, the provision and management of abortion should be treated in a manner cognizant with the general principles of informed consent in international human rights law, presuming capacity in all adults regardless of marital status and treatment sought, and recognizing the evolving capacity of young people in line with their internationally-protected rights.
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Affiliation(s)
- Fiona de Londras
- Birmingham Law School, University of Birmingham, B15 2TT, Birmingham, UK.
| | - Amanda Cleeve
- Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
- South General Hospital (Södersjukhuset), Stockholm, Sweden
| | - Maria I Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, USA
| | - Alana Farrell
- Birmingham Law School, University of Birmingham, B15 2TT, Birmingham, UK
| | | | - Antonella F Lavelanet
- Department of Sexual and Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
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18
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Kannappan A, Chaphekar A, Butler P, Middleman AB. Confidentiality and Contraception: Protecting Adolescent Care in Response to One State's "Parents' Bill of Rights". J Adolesc Health 2023; 73:650-654. [PMID: 37367703 DOI: 10.1016/j.jadohealth.2023.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 03/29/2023] [Accepted: 03/31/2023] [Indexed: 06/28/2023]
Abstract
PURPOSE This study aims to analyze parent responses to current strict Oklahoma confidentiality and consent laws in an outpatient subspecialty setting. METHODS A consent for treatment form including an explanation of the benefits of qualified confidential care for adolescents was given to parents of patients under 18 years of age. The form asked parents to waive the right to access confidential portions of the medical record, be present for the physical exam, be present for risk behavior discussions, and consent for hormonal contraception including a subdermal implant. Demographic information was collected using patient medical records. Data were analyzed using frequencies, chi-square, and t tests. RESULTS Of the 507 parent forms, 95% of total parents gave permission for providers to have confidential conversations with the patients, 86% allowed providers to examine the patient alone, 84% of parents allowed providers to prescribe contraception, and 66% gave permission for subdermal implant. New patient status, race, ethnicity, assigned sex at birth, and insurance type did not correlate with parents' willingness to provide permissions. There was a statistically significant difference between patient gender identity and percentage of parents who granted permission for a confidential physical exam. Groups more likely to discuss questions about confidential care with the health care provider included parents of new patients, Native American and Black patients, and cisgender female patients. DISCUSSION Despite laws that limit adolescent ability to access confidential care in Oklahoma, the majority of parents who were provided an explanatory document allowed their children the right to access this care.
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Affiliation(s)
- Anju Kannappan
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
| | - Anita Chaphekar
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; Division of Young Adult and Adolescent Medicine, Department of Pediatrics, University of San Francisco School of Medicine, San Francisco, California
| | - Patrick Butler
- Division of Adolescent Medicine, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Amy B Middleman
- Division of Adolescent Medicine, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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19
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You JGT, Potter JE, Mishuris RG. Electronic Health Record Adolescent Confidentiality in a Safety Net Setting. Appl Clin Inform 2023; 14:878-882. [PMID: 37640057 PMCID: PMC10620039 DOI: 10.1055/a-2161-0800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 08/25/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND The 21st Century Cures Act provides improved access to one's medical record but presents new challenges to adolescent confidentiality in the domain of health care information technology. Adolescent patients, who have the right to confidential care in certain areas as dictated by state law, face the prospect of parents and guardians erroneously accessing their confidential health information. OBJECTIVES Our institution, the largest safety net hospital in our region, sought to quantify the proportion of adolescent patient portal accounts likely being accessed by guardians and to implement corrective measures for the patient portal sign-up process in our electronic health record (EHR) system. METHODS We manually reviewed our institution's adolescent patient portal accounts based on email addresses associated with adolescents' accounts. We implemented EHR changes to address the potential for breach of confidentiality as a result of adolescent patient portal account creation by guardians. One intervention was creating a "guardrail rule" to prevent guardians from creating adolescent patient portal accounts with their own email addresses. After email reminders to adolescent patients to update their accounts, we deactivated accounts with concern for erroneous guardian access. RESULTS Sixty percent of our institution's adolescent patient portal accounts had possible direct access by guardians. Following requests to update account access, 425 (18.8%) of accounts had email addresses updated by adolescent patients and 1,830 (81.2%) accounts were deactivated. CONCLUSION More nuanced EHR functionality for adolescent patients and their guardians can help health care systems provide confidential, patient-centered care for adolescents, while allowing guardians to access appropriate health information to facilitate care. There is an opportunity for a national consensus on how adolescents and their guardians can access health information by patient portal.
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Affiliation(s)
- Jacqueline Guan-Ting You
- Department of Pathology, Massachusetts General Hospital/Brigham and Women's Hospital, Boston, Massachusetts, United States
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Julia Esther Potter
- Department of Pediatrics, Mass General Hospital for Children, Boston, Massachusetts, United States
| | - Rebecca Grochow Mishuris
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Digital, Mass General Brigham, Somerville, Massachusetts, United States
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20
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Muralidharan V, Burgart A, Daneshjou R, Rose S. Recommendations for the use of pediatric data in artificial intelligence and machine learning ACCEPT-AI. NPJ Digit Med 2023; 6:166. [PMID: 37673925 PMCID: PMC10482936 DOI: 10.1038/s41746-023-00898-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/03/2023] [Indexed: 09/08/2023] Open
Abstract
ACCEPT-AI is a framework of recommendations for the safe inclusion of pediatric data in artificial intelligence and machine learning (AI/ML) research. It has been built on fundamental ethical principles of pediatric and AI research and incorporates age, consent, assent, communication, equity, protection of data, and technological considerations. ACCEPT-AI has been designed to guide researchers, clinicians, regulators, and policymakers and can be utilized as an independent tool, or adjunctively to existing AI/ML guidelines.
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Affiliation(s)
- V Muralidharan
- Department of Dermatology, Stanford University, Stanford, USA.
| | - A Burgart
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, USA
| | - R Daneshjou
- Department of Dermatology, Stanford University, Stanford, USA
- Department of Biomedical Data Science, Stanford University, Stanford, USA
| | - S Rose
- Department of Health Policy, Stanford University, Stanford, USA
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21
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Owens C, Gray SJ, Carter K, Hoffman M, Mullen C, Hubach RD. Implementation Facilitators and Barriers for Primary Care Providers Prescribing Daily Oral PrEP to Adolescents in the United States. AIDS Patient Care STDS 2023; 37:379-393. [PMID: 37566536 DOI: 10.1089/apc.2023.0090] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2023] Open
Abstract
Primary care providers (PCPs) are critical in prescribing human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) to adolescents at risk of HIV. More research is needed to identify facilitators and barriers PCPs encounter in prescribing PrEP to eligible adolescents post-Food and Drug Administration (FDA) approval. This online cross-sectional survey examined the PrEP implementation facilitators and barriers among a national sample of PCPs in the United States. PCPs (n = 502) specializing in family medicine or pediatrics were recruited from a Qualtrics panel from July 15 to August 9, 2022. We analyzed the collected data using content analysis and applied the Expert Recommendations for Implementing Change (ERIC) to codebook creation and data analysis. We conducted a Fisher's exact chi-square test of independence to compare facilitator and barrier prevalence differences between participants who had and had not prescribed PrEP to an adolescent patient. Results demonstrate that (1) distributing prescriber-focused educational materials, (2) involving parents, (3) changing liability laws, (4) enhancing adolescent PrEP uptake and adherence, (5) changing clinical resources, and (6) using mass/social media to change community norms might be strategies that influence PCPs prescribing PrEP to eligible adolescent patients. Results from this study could facilitate the planning of hybrid implementation-effectiveness trials designed to determine the acceptability, feasibility, and effectiveness of implementation strategies in improving the practices of PCPs prescribing PrEP to at-risk adolescents.
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Affiliation(s)
- Christopher Owens
- Department of Health Behavior, School of Public Health, Texas A&M University, College Station, Texas, USA
| | - Samuel J Gray
- Department of Public Health, College of Health and Human Sciences, Purdue University, West Lafayette, Indiana, USA
| | - Kaileigh Carter
- Department of Health Behavior, School of Public Health, Texas A&M University, College Station, Texas, USA
| | - Matt Hoffman
- School of Nursing, Texas A&M University, Bryan, Texas, USA
| | - Cody Mullen
- Department of Public Health, College of Health and Human Sciences, Purdue University, West Lafayette, Indiana, USA
| | - Randolph D Hubach
- Department of Public Health, College of Health and Human Sciences, Purdue University, West Lafayette, Indiana, USA
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22
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Sisk BA, Antes AL, Bereitschaft C, Enloe M, Lin S, Srinivas M, Bourgeois F, DuBois JM. Engaging Adolescents in Using Online Patient Portals. JAMA Netw Open 2023; 6:e2330483. [PMID: 37610751 PMCID: PMC10448298 DOI: 10.1001/jamanetworkopen.2023.30483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/14/2023] [Indexed: 08/24/2023] Open
Abstract
Importance Many health care systems offer adolescents access to health information through online patient portals, but few studies have explored how to engage adolescents in using and benefiting from online portals. Objective To determine how US children's hospitals have attempted to encourage adolescent portal use, barriers to engaging adolescents, and ideal future goals for engagement. Design, Setting, and Participants This qualitative study performed structured qualitative interviews with informatics administrators from children's hospitals across the US between February and July 2022. Informatics administrators were employed by US health care systems that managed a children's hospital with at least 50 dedicated pediatrics beds. Data analysis was performed from November 2022 to January 2023. Main Outcomes and Measures This study used thematic analysis of (1) current steps that health care systems had taken to engage adolescents in using their online patient portals and (2) barriers to engaging adolescents and ideal future goals and outcomes of engagement. Results Among 58 total interviews with 65 informatics administrators who represented 63 hospitals across 58 health care systems, 6 themes of approaches to engaging adolescents in portal use were identified: (1) promoting and educating adolescents about portal enrollment, (2) establishing workflows to support enrollment, (3) seeking and incorporating feedback, (4) creating a culture or environment supporting engagement, (5) increasing portal utility, and (6) limited efforts. Barriers to engaging adolescents in portal use related to either (1) stakeholder investment, interest, and capabilities or (2) intersecting technical, ethical, and legal factors. Participants identified 4 ideal future efforts to engage adolescents: (1) develop adaptable private means of communication with adolescents, (2) use adolescent-centric user design, (3) enhance promotion and education about portal use, and (4) simplify and adapt workflows to encourage enrollment. Participants described 3 ideal outcomes of this future engagement: (1) provide education about current health, (2) prepare for transition to adulthood, and (3) improve digital health education of adolescents. Conclusions and Relevance In this qualitative study of informatics administrators, children's hospitals across the US were found to have varying degrees of efforts to engage adolescents in using their portals. Most of these efforts focused on supporting adolescent enrollment, but fewer efforts focused on making the portal useful and interesting to adolescents.
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Affiliation(s)
- Bryan A Sisk
- Division of Hematology/Oncology, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
- Bioethics Research Center, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Alison L Antes
- Bioethics Research Center, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Christine Bereitschaft
- Division of Hematology/Oncology, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Madi Enloe
- Division of Hematology/Oncology, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Sunny Lin
- General Medical Sciences, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Meghana Srinivas
- Division of Hematology/Oncology, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Fabienne Bourgeois
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - James M DuBois
- Bioethics Research Center, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
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23
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Jackman KMP, Ohene-Kyei ET, Barfield A, Atanda F, Smith R, Huettner S, Agwu A, Trent M. Patient Portal Privacy: Perspectives of Adolescents and Emerging Adults Living with HIV and the Parental/Guardian Role in Supporting Their Care. Appl Clin Inform 2023; 14:752-762. [PMID: 37729944 PMCID: PMC10511274 DOI: 10.1055/s-0043-1772685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 07/15/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Increasing the percentage of people living with human immunodeficiency virus (HIV), including youth, who are virally suppressed to 95% is an overall goal of the ending the HIV epidemic initiative. While patient portals have become ubiquitous, questions remain about how best to operationalize parental/guardian access to youth's patient portals in alignment with optimizing HIV care outcomes and patient preferences. This qualitative study focuses on understanding perspectives among youth with HIV (YHIV) about parental access to patient portals. METHODS Eligible participants were YHIV aged 13 to 25 years receiving care at an urban academic hospital. Semistructured individual/paired interviews were conducted between May 2022 and March 2023. Participants were asked to discuss thoughts on parental access to patient portals, and roles parents/guardians have in supporting their HIV care. Semistructured interviews were conducted with adolescent and emerging adult health care workers (HCWs) to gain perspectives on YHIV emergent themes. Audio-recorded interviews were transcribed verbatim, and we conducted thematic analysis using an inductive approach to identify codes and themes. RESULTS Sixteen YHIV and four HCWs participated in interviews. Parental roles in coordinating HIV care ranged from supporting YHIV needs for transportation, acquiring, and taking medications, to not having any role at all. Participants shared heterogeneous perspectives about their openness to share patient portal access with their parents/guardians. Perspectives were not strictly congruent along lines of participant age or parental roles in helping youth to manage HIV care. Sharing passwords emerged both as a pathway that YHIV grant access to their accounts and a source of confusion for clinicians when parents/guardians send messages using their child's account. CONCLUSION Findings suggest HCWs should initiate conversations with YHIV patients to determine preferences for parental/guardian access to their patient portal, educate on proxy access, and explain the extent of medical information that is shared with proxy accounts, regardless of age and perceived parental involvement in HIV care.
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Affiliation(s)
- Kevon-Mark P. Jackman
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Elise Tirza Ohene-Kyei
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Ashle Barfield
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Fopefoluwa Atanda
- Department of Biology, School of Computer, Mathematical and Natural Sciences, Morgan State University, Baltimore, Maryland, United States
| | - Raina Smith
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Steven Huettner
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Allison Agwu
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Maria Trent
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
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24
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Swedler J, Alderman EM. Special Issues in Adolescent Medicine: Medical and Legal Aspects of Care in Adolescent Medicine. Clin Obstet Gynecol 2023; 66:298-311. [PMID: 37204177 DOI: 10.1097/grf.0000000000000773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Providing medical care and managing the health care needs of adolescents can be a complex process. Knowing, which adolescents can consent to health care and the scope of services adolescents can consent to, what information can be kept confidential and from whom, under which circumstances information must be disclosed, and how to navigate parental involvement, is vital for the practice of adolescent medicine. This chapter aims to address some of these issues and assist health care providers in gaining knowledge and expertise in the optimal delivery of care for adolescents.
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Affiliation(s)
- Jane Swedler
- NYU Long Island School of Medicine and Adolescent Medicine, NYU Langone Hospital-Long Island
| | - Elizabeth M Alderman
- Division of Adolescent Medicine, Albert Einstein College of Medicine and The Children's Hospital at Montefiore, New York
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25
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Elias J, Gossey JT, Xi W, Sharko M, Robbins L, Bostwick S, Chang J, Lorenzi V, Giatzikis V, Scofi J, Trepp R, Lewis R. Sharing Clinical Notes while Protecting Adolescent Confidentiality and Maintaining Parental Insight. Appl Clin Inform 2023; 14:555-565. [PMID: 37130566 PMCID: PMC10371408 DOI: 10.1055/a-2084-4650] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 04/19/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND The 21st Century Cures Act mandates sharing electronic health records (EHRs) with patients. Health care providers must ensure confidential sharing of medical information with adolescents while maintaining parental insight into adolescent health. Given variability in state laws, provider opinions, EHR systems, and technological limitations, consensus on best practices to achieve adolescent clinical note sharing at scale is needed. OBJECTIVES This study aimed to identify an effective intervention process to implement adolescent clinical note sharing, including ensuring adolescent portal account registration accuracy, across a large multihospital health care system comprising inpatient, emergency, and ambulatory settings. METHODS A query was built to assess portal account registration accuracy. At a large multihospital health care system, 80.0% of 12- to 17-year-old patient portal accounts were classified as inaccurately registered (IR) under a parent or registration accuracy unknown (RAU). To increase accurately registered (AR) accounts, the following interventions were pursued: (1) distribution of standardized portal enrollment training; (2) patient outreach email campaign to reregister 29,599 portal accounts; (3) restriction of access to remaining IR and RAU accounts. Proxy portal configurations were also optimized. Subsequently, adolescent clinical note sharing was implemented. RESULTS Distribution of standardized training materials decreased IR and increased AR accounts (p = 0.0492 and 0.0058, respectively). Our email campaign (response rate: 26.8%) was most effective in decreasing IR and RAU accounts and increasing AR accounts (p < 0.002 for all categories). Remaining IR and RAU accounts, 54.6% of adolescent portal accounts, were subsequently restricted. Postrestriction, IR accounts continued declining significantly (p = 0.0056). Proxy portal enhancements with interventions deployed increased proxy portal account adoption. CONCLUSION A multistep intervention process can be utilized to effectively implement adolescent clinical note sharing at a large scale across care settings. Improvements to EHR technology, portal enrollment training, adolescent/proxy portal settings, detection, and automation in reenrollment of inaccurate portal accounts are needed to maintain integrity of adolescent portal access.
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Affiliation(s)
- Jonathan Elias
- Department of Primary Care, Weill Cornell Medicine, New York, New York, United States
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, United States
| | - J. Travis Gossey
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, United States
- Department of Medicine, Weill Cornell Medical Center, New York, New York, United States
| | - Wenna Xi
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, United States
| | - Marianne Sharko
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, United States
- Department of Pediatrics, Weill Cornell Medical Center, New York, New York, United States
| | - Laura Robbins
- Department of Pediatrics, Morgan Stanley Children's Hospital, New York, New York, United States
| | - Susan Bostwick
- Department of Pediatrics, Weill Cornell Medical Center, New York, New York, United States
| | - Jane Chang
- Department of Pediatrics, Weill Cornell Medical Center, New York, New York, United States
| | - Virginia Lorenzi
- NewYork-Presbyterian Hospital, New York, New York, United States
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York, United States
| | | | - Jean Scofi
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, United States
- Department of Emergency Medicine, Weill Cornell Medical Center, New York, New York, United States
| | - Richard Trepp
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York, New York, United States
| | - Rachel Lewis
- Department of Pediatrics, ColumbiaDoctors, New York, New York, United States
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Sarabu C, Sharko M, Petersen C, Galvin H. Shifting into Action: from Data Segmentation to Equitable Interoperability for Adolescents (and Everyone Else). Appl Clin Inform 2023; 14:544-554. [PMID: 37467783 PMCID: PMC10356185 DOI: 10.1055/s-0043-1769924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/19/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Technological improvements and, subsequently, the federal 21st Century Cures Act have resulted in increased access to and interoperability of electronic protected health information (ePHI). These not only have many benefits, but also have created unique challenges for privacy and confidentiality for adolescent patients. The inability to granularly protect sensitive data and a lack of standards have resulted in limited confidentiality protection and inequitable access to health information. OBJECTIVES This study aimed to understand the challenges to safe, equitable access, and interoperability of ePHI for adolescents and to identify strategies that have been developed, ongoing needs, and work in progress. METHODS Shift, a national task force formalized in 2020, is a group of more than 200 expert stakeholder members working to improve functionality to standardize efforts to granularly identify and protect sensitive ePHI to promote equitable interoperability. RESULTS Shift has created high-priority clinical use cases and organized challenges into the areas of Standards and Terminology; Usability and Implementation; and Ethics, Legal, and Policy. CONCLUSION Current technical standards and value sets of terminology for sensitive data have been immature and inconsistent. Shift, a national diverse working group of stakeholders, is addressing challenges inherent in the protection of privacy and confidentiality for adolescent patients. The diversity of expertise and perspectives has been essential to identify and address these challenges.
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Affiliation(s)
- Chethan Sarabu
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, United States
| | - Marianne Sharko
- Department of Healthcare Policy & Research, Division of Health Informatics, Weill Cornell Medical College, New York, New York, United States
| | - Carolyn Petersen
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, Minnesota, United States
| | - Hannah Galvin
- Department of Information Technology, Cambridge Health Alliance, Tufts University School of Medicine, Cambridge, Massachusetts, United States
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Abstract
Although vaccines are important for all age groups, issues of vaccine uptake and vaccine hesitancy have particular salience for the adolescent and young adult age group. This article reviews the importance of vaccination for adolescents and young adults, the variability in uptake of different vaccines, the reasons for vaccine hesitancy for this age group, and the legal framework for consent for vaccination. One important difference between vaccine hesitancy for adolescents and hesitancy for younger children or adults is the unique developmental, clinical, ethical, and legal context in which the decision to vaccinate is made.
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Affiliation(s)
- Abigail English
- Center for Adolescent Health & the Law, PO Box 3795, Chapel Hill, NC 27515, USA; Gillings School of Global Publlic Health, University of North Carolina, Chapel Hill.
| | - Amy B Middleman
- Department of Pediatrics, University of Oklahoma Health Sciences Center, 1200 Children's Avenue, Suite 12200, Oklahoma City, OK 73104, USA
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Stettner NM, Lavelle EN, Cafferty P. Who decides? Consent for healthcare decisions of minors in the United States. Curr Opin Pediatr 2023; 35:275-280. [PMID: 36647569 DOI: 10.1097/mop.0000000000001218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to examine when parents and legal guardians have the authority to make medical decisions on behalf of the minors in their care, when the decisions of healthcare professionals may supersede those of parents and guardians, and under what conditions minors can make healthcare decisions for themselves. RECENT FINDINGS The coronavirus disease 2019 (COVID-19) pandemic has reignited discussion of who should make healthcare decisions for minors. Though serious adverse reactions to COVID-19 vaccines are rare, hesitancy toward pediatric COVID-19 vaccination is prevalent among parents in the United States. This has contributed to large numbers of minors who are not up-to-date or not fully vaccinated against severe acute respiratory syndrome coronavirus 2 infection. Surveys reveal a majority of minors in the United States are willing to receive a COVID-19 vaccine. A number of scholars have recommended allowing adolescents the ability to consent to COVID-19 vaccination without parental approval. SUMMARY Allowing adolescents with a minimum age of 15 to consent to vaccination without parental or guardian approval will more quickly enable adolescents to receive new vaccines as they become available, such as the COVID-19 bivalent vaccine.
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Bedgood M, Rabbani N, Brown C, Goldstein R, Carlson JL, Steinberg E, Powell A, Pageler NM, Morse K. The Prevalence of Confidential Content in Adolescent Progress Notes Prior to the 21st Century Cures Act Information Blocking Mandate. Appl Clin Inform 2023; 14:337-344. [PMID: 37137339 PMCID: PMC10156443 DOI: 10.1055/s-0043-1767682] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 02/16/2023] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND The 21st Century Cures Act information blocking final rule mandated the immediate and electronic release of health care data in 2020. There is anecdotal concern that a significant amount of information is documented in notes that would breach adolescent confidentiality if released electronically to a guardian. OBJECTIVES The purpose of this study was to quantify the prevalence of confidential information, based on California laws, within progress notes for adolescent patients that would be released electronically and assess differences in prevalence across patient demographics. METHODS This is a single-center retrospective chart review of outpatient progress notes written between January 1, 2016, and December 31, 2019, at a large suburban academic pediatric network. Notes were labeled into one of three confidential domains by five expert reviewers trained on a rubric defining confidential information for adolescents derived from California state law. Participants included a random sampling of eligible patients aged 12 to 17 years old at the time of note creation. Secondary analysis included prevalence of confidentiality across age, gender, language spoken, and patient race. RESULTS Of 1,200 manually reviewed notes, 255 notes (21.3%) (95% confidence interval: 19-24%) contained confidential information. There was a similar distribution among gender and age and a majority of English speaking (83.9%) and white or Caucasian patients (41.2%) in the cohort. Confidential information was more likely to be found in notes for females (p < 0.05) as well as for English-speaking patients (p < 0.05). Older patients had a higher probability of notes containing confidential information (p < 0.05). CONCLUSION This study demonstrates that there is a significant risk to breach adolescent confidentiality if historical progress notes are released electronically to proxies without further review or redaction. With increased sharing of health care data, there is a need to protect the privacy of the adolescents and prevent potential breaches of confidentiality.
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Affiliation(s)
- Michael Bedgood
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, United States
- Information Services, Stanford Children's Health, Palo Alto, California, United States
- California Department of Public Health, Coronavirus Science Branch, Richmond, California, United States
| | - Naveed Rabbani
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, United States
- Information Services, Stanford Children's Health, Palo Alto, California, United States
| | - Conner Brown
- Information Services, Stanford Children's Health, Palo Alto, California, United States
| | - Rachel Goldstein
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, United States
- Information Services, Stanford Children's Health, Palo Alto, California, United States
| | - Jennifer L. Carlson
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, United States
- Information Services, Stanford Children's Health, Palo Alto, California, United States
| | - Ethan Steinberg
- Stanford Center for Biomedical Informatics Research, Stanford University, Palo Alto, California, United States
| | - Austin Powell
- Information Services, Stanford Children's Health, Palo Alto, California, United States
| | - Natalie M. Pageler
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, United States
- Information Services, Stanford Children's Health, Palo Alto, California, United States
| | - Keith Morse
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, United States
- Information Services, Stanford Children's Health, Palo Alto, California, United States
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Xie J, Hogan A, McPherson T, Pageler N, Lee T, Carlson J. Creating a Guardrail System to Ensure Appropriate Activation of Adolescent Portal Accounts. Appl Clin Inform 2023; 14:258-262. [PMID: 36652961 PMCID: PMC10076104 DOI: 10.1055/a-2015-0964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 01/13/2023] [Indexed: 01/20/2023] Open
Abstract
The parent of an adolescent patient noticed an upcoming appointment in the patient's portal account that should have remained confidential to the parent. As it turned out, this parent was directly accessing their child's adolescent patient portal account instead of using a proxy account. After investigation of this case, it was found that the adolescent account had been activated with the parent's demographic (i.e., phone/email) information. This case illustrates the challenges of using adult-centric electronic health record (EHR) systems and how our institution addressed the problem of incorrect portal account activations.Confidentiality is fundamental to providing healthcare to adolescents. To comply with the 21st Century Cures Act's information blocking rules, confidential information must be released to adolescent patients when appropriate while also remaining confidential from their guardians. While complying with this national standard, systems of care must also account for interstate variability in which services allow for confidential adolescent consent. Unfortunately, there are high rates of guardian access to adolescent portal accounts which may lead to unintended disclosure of confidential information. Therefore, measures must be taken to minimize the risk of inadvertent confidentiality breaches via adolescent patient portals.Our institution implemented a guardrail system that checks the adolescent patient's contact information against the contact information of their parent/guardian/guarantor. This guardrail reduced the rate of account activation errors after implementation. However, the guardrail can be bypassed when demographic fields are missing. Thus, ongoing efforts to create pediatric-appropriate demographic fields, clearly distinguishing patient from proxy, in the EHR and workflows for registration of proxy accounts in the patient portal are needed.
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Affiliation(s)
- James Xie
- Information Systems, Stanford Children's Health, Stanford, California, United States
| | - Adam Hogan
- Information Systems, Stanford Children's Health, Stanford, California, United States
| | - Tom McPherson
- Information Systems, Stanford Children's Health, Stanford, California, United States
| | - Natalie Pageler
- Information Systems, Stanford Children's Health, Stanford, California, United States
| | - Tzielan Lee
- Information Systems, Stanford Children's Health, Stanford, California, United States
| | - Jennifer Carlson
- Information Systems, Stanford Children's Health, Stanford, California, United States
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Chernick LS, Bugaighis M, Britton L, Cruz AT, Goyal MK, Mistry RD, Reed JL, Bakken S, Santelli JS, Dayan PS. Factors influencing the conduction of confidential conversations with adolescents in the emergency department: A multicenter, qualitative analysis. Acad Emerg Med 2023; 30:99-109. [PMID: 36478023 DOI: 10.1111/acem.14638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/14/2022] [Accepted: 11/15/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Health care providers (HCPs) in the emergency department (ED) frequently must decide whether to conduct or forego confidential conversations with adolescent patients about sensitive topics, such as those related to mental health, substance use, and sexual and reproductive health. The objective of this multicenter qualitative analysis was to identify factors that influence the conduct of confidential conversations with adolescent patients in the ED. METHODS In this qualitative study, we conducted semistructured interviews of ED HCPs from five academic, pediatric EDs in distinct geographic regions. We purposively sampled HCPs across gender, professional title, and professional experience. We used the Theoretical Domains Framework (TDF) to develop an interview guide to assess individual and system-level factors affecting HCP behavior regarding the conduct of confidential conversations with adolescents. Enrollment continued until we reached saturation. Interviews were recorded, transcribed, and coded by three investigators based on thematic analysis. We used the coded transcripts to collaboratively generate belief statements, which are first-person statements that reflect shared perspectives. RESULTS We conducted 38 interviews (18 physicians, 11 registered nurses, five nurse practitioners, and four physician assistants). We generated 17 belief statements across nine TDF domains. Predominant influences on having confidential conversations included self-efficacy in speaking with adolescents alone, wanting to address sexual health complaints, maintaining patient flow, experiencing parental resistance and limited space, and having inadequate resources to address patient concerns and personal preconceptions about patients. Perspectives divided between wanting to provide focused medical care related only to their chief complaint versus self-identifying as a holistic medical HCP. CONCLUSIONS The factors influencing the conduct of confidential conversations included multiple TDF domains, elucidating how numerous intersecting factors influence whether ED HCPs address sensitive adolescent health needs. These data suggest methods to enhance and facilitate confidential conversations when deemed appropriate in the care of adolescents in the ED.
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Affiliation(s)
- Lauren S Chernick
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York, New York, USA.,Department of Population and Family Health, Columbia University, New York, New York, USA
| | - Mona Bugaighis
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Laura Britton
- Department of Nursing, Columbia University Irving Medical Center, New York, New York, USA
| | - Andrea T Cruz
- Divisions of Emergency Medicine and Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Monika K Goyal
- Department of Pediatrics, Children's National Hospital, George Washington University, Washington, DC, USA
| | - Rakesh D Mistry
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jennifer L Reed
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Ohio, Cincinnati, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Ohio, Cincinnati, USA
| | - Suzanne Bakken
- Department of Nursing and Bioinformatics, Columbia University Irving Medical Center, New York, New York, USA
| | - John S Santelli
- Department of Population and Family Health, Columbia University, New York, New York, USA.,Department of Pediatrics, Columbia University Irving Medical Center, New York, New York, USA
| | - Peter S Dayan
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York, New York, USA
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32
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Camenga DR, Barelli P. It Is Time for Pediatric Hospitalists to Treat Opioid Use Disorder. Hosp Pediatr 2023; 13:e34-e36. [PMID: 36683463 DOI: 10.1542/hpeds.2022-006940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Deepa R Camenga
- Departments of Emergency Medicine & Pediatrics.,Yale Program in Addiction Medicine, New Haven, Connecticut
| | - Peter Barelli
- Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Yale Program in Addiction Medicine, New Haven, Connecticut
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33
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Carlson JL, Pageler N, McPherson T, Anoshiravani A. Providing Online Portal Access to Families of Adolescents and Young Adults with Diminished Capacity at an Academic Children's Hospital: A Case Report. Appl Clin Inform 2023; 14:128-133. [PMID: 36792056 PMCID: PMC9931492 DOI: 10.1055/s-0043-1760847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 12/16/2022] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND For caregivers of adolescents and young adults with severe cognitive deficits, or "diminished capacity," access to the medical record can be critical. However, this can be a challenge when utilizing the electronic health record (EHR) as information is often restricted in order to protect adolescent confidentiality. Having enhanced access for these proxies would be expected to improve engagement with the health system for the families of these medically complex adolescents and young adults. OBJECTIVES To describe a process for granting full EHR access to proxies of adolescents with diminished capacity and young adults who are legally conserved while respecting regulations supporting adolescent confidentiality. METHODS The first step in this initiative was to define the "diminished capacity" access class for both adolescents and young adults. Once defined, workflows utilizing best practice alerts were developed to support clinicians in providing the appropriate documentation. In addition, processes were developed to minimize the possibility of erroneously activating the diminished capacity access class for any given patient. To enhance activation, a support tool was developed to identify patients who might meet the criteria for diminished capacity proxy access. Finally, outreach and educations were developed for providers and clinics to make them aware of this initiative. RESULTS Since activating this workflow, proxies of 138 adolescents and young adults have been granted the diminished capacity proxy access class. Approximately 54% are between 12 and 17 years with 46% 18 years and older. Proxies for both age groups have engaged with portal functionality at higher rates when compared to institutional rates of use by proxies of the general pediatric population. CONCLUSION With this quality improvement initiative, we were able to enhance EHR access and engagement of families of some of the most complex adolescent and young adult patients without inadvertently compromising adolescent confidentiality.
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Affiliation(s)
- Jennifer L. Carlson
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States
| | - Natalie Pageler
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States
| | - Tom McPherson
- Information Services, Stanford Medicine Children's Health, Palo Alto, California, United States
| | - Arash Anoshiravani
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States
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34
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Marks A. A Complex Matter: Parental Perspectives on Adolescent Health-Related Confidentiality. J Adolesc Health 2023; 72:3-4. [PMID: 36528361 DOI: 10.1016/j.jadohealth.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 10/06/2022] [Indexed: 12/23/2022]
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35
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Affiliation(s)
- Abigail English
- Center for Adolescent Health & the Law, Chapel Hill, North Carolina
| | - Carol A Ford
- University of Pennsylvania and The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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