This study relates to the facilitation of the use of computerized clinical practice guidelines (CPG) in the Military Health System (MHS). The goals of this project are: 1) Determine critical AHLTA usability issues and develop an improved prototype; 2) compare clinicians' human performance with AHLTA against the improved prototype; 3) identify issues with aCPGs and develop one aCPG and the AHLTA prototype with user-centered design principles; and 4) compare human performance of the current AHLTA (AIM) aCPGs against the prototype aCPG.

This project continues ongoing work using functional genomics to gain insights into the path physiology of early onset Coronary Artery Disease. That inflammation has a central role in the atherosclerotic process has been amply demonstrated and has focused on inflammation in the development of the atherosclerotic plaque and in coronary atherosclerosis. The premise of this project is that the cellular mediators of this inflammation, the circulating white blood cells, display unique genetic expression profiles that are best demonstrated in patients with premature cardiovascular atherosclerotic disease.

The overall hypothesis of the Automated Clinical Practice Guideline (ACPG) project is that the use of technology provides timely information, and business process re-engineering that efficiently incorporates that technology in the clinical process will improve clinical processes, patient outcomes, and provider satisfaction. Three ACPG projects have been completed: Diabetes, Tobacco Use Cessation, and VitalSign/Check In. Three ACPG projects are in process: Uncomplicated Pregnancy, Preventive Services, and Cardiovascular Disease. The newest project is Medication Reconciliation, which focuses on medication errors. Specific Aims: 1) To complete the Uncomplicated Pregnancy ACPG evaluation, assessing the effect of the intervention on prenatal care utilization and other variables; 2) To complete the Preventive Services evaluation, assessing the effect of the Preventive Services ACPG on adherence to the guidelines; 3) To complete the Cardiovascular Disease ACPG, measuring changes in compliance with the JCAHO HF-1 and HF-4 National Quality Measures; and 4) To implement and evaluate the effects of a new medication reconciliation system on the number of medication discrepancies and potential adverse drug events.

This project's overall intent is to promote new patterns of collaboration among industry consortia, university researchers and government agencies, with an emphasis on commercialization, empirical knowledge, and the public good. This program of research is designed to establish an ongoing effort for data collection and analysis, and to advance the quantification of triple-helix models and methodologies. This research will allow for broad data collection and analysis, longitudinal examination of diverse factors, and perpetual feedback loop to permit the continual refinement of understanding knowledge bases while informing new projects and collaborative designs.

This on going project is developing new bioengineering technologies. The initial work has focused on setting up infrastructure and beginning the development of techniques and knowledge to advance corneal transplantation and repair. The multi and interdisciplinary approach seeks to enhance surgical intervention in corneal disease and vision restoration by combining new technologies in human cell culture, synthetic biopolymer development and new surgical delivery systems. Now in it's third year, The imediate goals of the project are to determine whether corneal disease of the endothelium can be treated and vision restored by innovative technologies that combine bioengineered cells and polymeric materials in concert with new surgical delivery systems. This is the third year of the research project. An animal study on transplanting full thickness corneas that incorporate human bioengineered endothelial cells will be completed early in this year's study. A second objective in testing the hypothesis is to develop biocompatible polymeric substrates that will be coated with human bioengineered endothelial cells to mitigate the issues surrounding the availability of and transmission of infections by donor tissues. The third objective is to develop a device to be used in surgery that will deploy the folded polymer/endothelium sheet into a minimal incision and unfold the sheet in the correct orientation.

The technical objective of this project is to provide the tools, methods and techniques required for the development of a TATRC Western Field Office and evaluation using objective metrics to judge the impact of regional management, with special focus on business case analysis in the area of intellectual property development and technology transfer. The proposal will address 4 tasks in order to meet this objective. Task one will be to establish the infrastructure of the Field Office in such a way as to institute the means of close interaction between USAMRMC/TATRC research managers and their Principal Investigators located at a distance. Task two will focus on the establishment of proven and successful TATRC business practices in the Pacific/West region. Task three will focus on creating close working relationships with two nationally unique assets found only in the Pacific/West region, UCLA University Hospital and University of Southern California. Task four will be to create a dynamic process through which to transition selected technologies from advanced research to advanced development.

The overall goal of the proposed research is to develop, test, and seek FDA approval for the versaHSDI instrument: a novel fluorescence and reflectance spectroscopic cancer imaging device based on a versatile, modular design. The versaHSDI system will facilitate early detection of neoplasia in a variety of organs, through use of interchangeable imaging probe modules adapted to endoscopic and/or superficial detection needs. The initial focus of the versaHSDI effort will be to detect colorectal cancer with subsequent development targeting nonmelanoma skin cancer detection. The approach and effort will leverage experience gained by developing Science & Technology International's hyperspectral diagnostic imaging (HSDI) system for detecting cervical cancer. The HSDI cervical instrument transmits white light for collecting reflectance imagery and ultraviolet light for collecting visible induced-fluorescence imagery. The HSDI technology employs multi- or hyper-spectral cameras to measure image color in up to hundreds of spectral bands, thereby revealing tissue features not visible to the human eye or other imaging technologies.

The ongoing focus of the versaHSDI effort is to conduct imaging and algorithm research and development and technology development for cancer detection in the cervix. This study aims to build a new screening and triage instrument for cervical cancer called the Cervical MD. This instrument will be a "smart" imaging system, containing onboard signal processing algorithms; thereby, providing real-time feedback to the clinician at the time of the examination. It is hypothesized that acquiring and analyzing digital imaging data can provide clinically significant, pathologically accurate diagnostic information, and that this can be done non-invasively and in real time using versaHSDI and Virtual Biopsy technologies. The results of these analyses can be compiled to formulate a collective output displayed to the physician as a diagnostic aid, with initial application to cervical cancer.

The proposal seeks to develop Computer Aided Diagnosis (CAD) systems to improve the diagnosis and treatment of precancer, cancer and other disease of the Colon. The broad 3 year plan develops a "non invasive" means to combine spectral and hyper-spectral imaging, image processing, tissue databases and algorithms to develop systems that aid clinicians in decision making, treatment and monitoring. The current year proposal defines a goal of developing an "off line" Colon CAD system for white light colonoscopy. Specific long term aims are to: 1. develop and test a Colon CAD system for white-light colonoscopy that enables real-time automated screening (Screen) and rapid tissue classification (Stare); 2. develop a point-probe (Probe) to measure tissue in situ to discriminate cancer from non-cancer; 3. facilitate treatment planning (Plan) by developing innovative colon visualization software that generates a 3D virtual colon from standard endoscopic video data.

This project will identify individual and organizational level facilitators and barriers to the implementation of an OSS EHR (Open Source Software Electronic Health Records) system in rural healthcare facilities that are perceived by key institutional administrators and healthcare providers (physicians and nurses). Individual and organizational level facilitators and barriers will be assessed by collecting data on characteristics, attitudes, knowledge, concerns and expectations about the EHR deployment. Measurements will be utilized to assess the extent to which the use of OSS EHR reduces the financial barriers of EHR implementation in comparison to published studies.

The investigator seeks to build upon previous work invested in prototyping a remote ICU, technology-based clinical support platform. The application is currently in place and represents the standard of care at the Tripler Army Medical Center Hawaii where it projects intensive care clinician expertise to Guam Naval Hospital. This test bed will be used to study the application of telecommunication technologies, and mannequin-based simulation to team training and performance. Performance metrics will be applied to assess the effect of distance and isolation as well as the maintenance of skills over time.

In this study, researchers will assess the comparative effect of group versus one-on-one clinician EMR teaching/integration. The specific hypotheses are that one-on-one teaching/integration model (as opposed to the group model) will result in: 1. a greater increase in clinician post-teaching computer and EMR functionality skills; 2. a greater increase in clinician post-teaching EMR and ACPG use rates; 3. higher levels of clinician self-reported perceived ease of use and perceived usefulness of the EMR and ACPGs; and 4. higher levels of satisfaction with the teaching model.

The proposal seeks to enhance a large scale of medication distribution through development and study of a computerized, rather than paper based method. The development goal is to construct a hardware and software system that is easy to use, reliable, redundant and deployable, that can increase the efficiency of mass medication delivery. The research goal is to study the developed system to document and validate the process with attention to efficiency in the form of time saving and efficacy in the form of dosage error rates.

To establish the Pacific Pediatric Advanced Care Initiative a broadly collaborative group including the University of Hawaii (UH), Tripler Army Medical Center (TAMC), the University Of Pittsburgh Medical Center (UPMC) and the Kapiolani Womens and Childrens Medical Center (KWCMC). Specific Aim 1 is to establish a new extracorporeal life support (ECLS) program to provide the highest standards for patient care. The program will further execute outcomes research to confirm that the Center outcomes can equal national Extracorporeal Life Support Organization (ELSO) benchmarks. Specific Aim 2 is to create a basic science research program to complement the clinical ECLS program. The program will provide valuable research capability to support the graduate medical education requirements of the TAMC and the Department of Defense. Basic science research well specifically examine 1) use of extracorporeal membrane oxygenation (ECMO) in endotoxin induced septic shock in a porcine model; 2) the use of blood substitutes in place of whole blood as a heart-lung machine priming substitute; 3) in a porcine model study the effect of ECMO in multisystem organ failure related to septic shock. Specific Aim 3 is to create a unique ECLS training curriculum that integrates the use of manikin simulation for training, testing and evaluation.

This study is designed to determine the impact of an automated early warning system that identifies heart and respiratory rate abnormalities as well as unauthorized bed exit on nurse workflow and acceptance of information technology in nurse-care processes at three VA hospitals. The study methods include baseline and post-intervention work sampling studies, use of validated surveys, focus groups, and examination of nurse-to-patient ratios and other administrative data.

This two-phase project aims to investigate the impact of two simulation based platforms on triage training and performance. Phase I will evaluate the impact of manikin simulation on the acquisition of triage skills will be measured. This phase is designed to explore the successive exposure of first responder trainees to a series of mass casualty triage scenarios using manikins. Phase II will focus on the development and validation of a three-dimensional (3D) immersive Virtual Reality application that will serve as the technological platform.

This research focuses on the development of Technology-Enabled Learning and Intervention Systems (TELIS), educational products and applications using a design model that involves an interdisciplinary approach based on three related action areas: develop, apply, and measure. They are applying this methodology to three educational projects. The projects are: Virtual Reality-Nephron (Develop); Virtual Triage Training (Apply and Measure) and Virtual reality motor-skills Trainer (Apply and Measure).

The project is based on the premise that a positive culture of safety, a "safety climate," is essential to the provision of safer patient care. A measure of this climate, the Safety Climate Survey is currently being used regularly at the participating institution and is utilized in this proposal as a validated measure. The study will introduce high-fidelity human patient simulator (Manikin)-based training to a rural hospital crisis team training (CTT) for the Cardiac Arrest Response Teams at the participant hospital. The study proposes to measure the impact of this novel educational intervention - a manikin-based, safety-focused provider education curriculum - on the safety culture in a rural hospital emergency response team and, secondarily, across the entire organization as a product of "contamination." It is hypothesized that providers become more open to organizational and personal practice changes that support improved patient safety, and that a similar change is propagated throughout an organization because of organizational commitment to process improvement, demonstrated by the provision of advanced training to some staff members.

The investigators propose a first of its kind, randomized, controlled study of the use of video game-enhanced exercise equipment to improve exercise adherence and self-efficacy in overweight adults. The concept is that pairing exercise with highly reinforcing interactive simulations can produce measurable improvement in specific parameters. The study focuses on a population that does not routinely exercise. Participants who have a BMI of 25 or greater, who are cleared for physical exercise, and who are medically stable will be recruited and randomized into an experimental group and a control group. The study will utilize repeated measures over three time periods (baseline, three months, six months). Outcome measures will be gathered including self report surveys of health and quality-of-life and self-efficacy.

This study uses principles of cue reactivity to investigate the biometric signature associated with elicited stress and tobacco craving. It is anticipated that comparisons of physiological responses to stress and craving among different groups will enable researchers to differentiate arousal due to stress reactivity and craving. The proposed research hypothesizes that biometric data can identify and predict arousal patterns associated with tobacco use behavior. It is further hypothesized that examining physiological and psychological patterns of cue reactivity can differentiate between psychological craving and physiological arousal in smokers. This study aims to refine statistical algorithms that will accurately identify and predict tobacco use based on patterns of physiological arousal and psychological craving. It is anticipated that these algorithms can be used in future research to inform tailored interventions that foster behavior change. Participants in this semi-randomized four-group pre-post will include non-smokers; former smokers; current smokers; and deprived smokers. Baseline data will be collected for 3 days including electronic diary report of daily routines and continuous biometric data. Individual experimental sessions will be structured as follows: 1) Attenuation Phase: 30 minutes of baseline sensor calibration; 2) Standard elicited stress activity to collect baseline readings of arousal; 3) Mediated stress activity consisting of validated video clips to elicit cue-specific arousal as participants adjust a subjective rating dial to indicate arousal levels. It is expected that long-term outcomes will create a platform for developing new behavioral health technologies that incorporate autonomous agents; the provision of just-in-time information; and predictive algorithms.

The aim of this proposed research is to demonstrate the potential performance increase when operator's physiologic signals are incorporated as an integral part of their interface to a computer or system. Such interfaces, known as physiologic system interfaces (PSI), use signals from the heart, brain, and skin to provide information to control systems of medical, aircraft, computer, and unmanned vehicle platforms. Using Archinoetic's functional near infrared (fNIR) sensor as a PSI input, multiple studies are designed to: 1) improve operator performance by augmenting a computer environment based on an operator's physiology; 2) develop an alternative hands-free interaction technique based on tactile feedback; and 3) use biological signals inherent in our sensor to monitor warfighter vital signs.