Publications by authors named "José F Flórez-Arango"

15 Publications

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Telehealth and the COVID-19 Pandemic: International Perspectives and a Health Systems Framework for Telehealth Implementation to Support Critical Response.

Yearb Med Inform 2021 Apr 21. Epub 2021 Apr 21.

Sri Sathya Sai Central Trust, Puttaparthi, India.

Objectives: Telehealth implementation is a complex systems-based endeavour. This paper compares telehealth responses to (COrona VIrus Disease 2019) COVID-19 across ten countries to identify lessons learned about the complexity of telehealth during critical response such as in response to a global pandemic. Our overall objective is to develop a health systems-based framework for telehealth implementation to support critical response.

Methods: We sought responses from the members of the International Medical Informatics Association (IMIA) Telehealth Working Group (WG) on their practices and perception of telehealth practices during the times of COVID-19 pandemic in their respective countries. We then analysed their responses to identify six emerging themes that we mapped to the World Health Organization (WHO) model of health systems.

Results: Our analysis identified six emergent themes. (1) Government, legal or regulatory aspects of telehealth; (2) Increase in telehealth capacity and delivery; (3) Regulated and unregulated telehealth; (4) Changes in the uptake and perception of telemedicine; (5) Public engagement in telehealth responses to COVID-19; and (6) Implications for training and education. We discuss these themes and then use them to develop a systems framework for telehealth support in critical response.

Conclusion: COVID-19 has introduced new challenges for telehealth support in times of critical response. Our themes and systems framework extend the WHO systems model and highlight that telemedicine usage in response to the COVID-19 pandemic is complex and multidimensional. Our systems-based framework provides guidance for telehealth implementation as part of health systems response to a global pandemic such as COVID-19.
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http://dx.doi.org/10.1055/s-0041-1726484DOI Listing
April 2021

Telehealth and the COVID-19 Pandemic: International Perspectives and a Health Systems Framework for Telehealth Implementation to Support Critical Response.

Yearb Med Inform 2021 Apr 21. Epub 2021 Apr 21.

Sri Sathya Sai Central Trust, Puttaparthi, India.

Objectives: Telehealth implementation is a complex systems-based endeavour. This paper compares telehealth responses to (COrona VIrus Disease 2019) COVID-19 across ten countries to identify lessons learned about the complexity of telehealth during critical response such as in response to a global pandemic. Our overall objective is to develop a health systems-based framework for telehealth implementation to support critical response.

Methods: We sought responses from the members of the International Medical Informatics Association (IMIA) Telehealth Working Group (WG) on their practices and perception of telehealth practices during the times of COVID-19 pandemic in their respective countries. We then analysed their responses to identify six emerging themes that we mapped to the World Health Organization (WHO) model of health systems.

Results: Our analysis identified six emergent themes. (1) Government, legal or regulatory aspects of telehealth; (2) Increase in telehealth capacity and delivery; (3) Regulated and unregulated telehealth; (4) Changes in the uptake and perception of telemedicine; (5) Public engagement in telehealth responses to COVID-19; and (6) Implications for training and education. We discuss these themes and then use them to develop a systems framework for telehealth support in critical response.

Conclusion: COVID-19 has introduced new challenges for telehealth support in times of critical response. Our themes and systems framework extend the WHO systems model and highlight that telemedicine usage in response to the COVID-19 pandemic is complex and multidimensional. Our systems-based framework provides guidance for telehealth implementation as part of health systems response to a global pandemic such as COVID-19.
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http://dx.doi.org/10.1055/s-0041-1726484DOI Listing
April 2021

SIM-CIG: A Serious Game to Practice and Improve Clinical Guidelines Adoption Based on Computer-Interpretable Guidelines.

Stud Health Technol Inform 2019 Aug;264:1997-1998

Department of Simulation in Healthcare, Universidad Pontificia Bolivariana, Medellin, Antioquia, Colombia.

Serious games have been used to increase the accuracy and usege of clinical guidelines during routine clinical practice. This document presents the development of a serious game called SIM-GIC, a video game designed to simulate virtual patients and evaluate the decision making of players based on computer-interpretable clinical guidelines. The system is currently being developed with a content focus on antenatal care guidelines, where a number of obstetric guidelines were coded in XML files.
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http://dx.doi.org/10.3233/SHTI190753DOI Listing
August 2019

Design of an Information System for Palliative Care: User Analysis.

Stud Health Technol Inform 2018 ;250:11-13

Universidad Pontificia Bolivariana, Medellín, Antioquia, Colombia.

Objective: To explore the demographic factors and the level of knowledge related to information and communication technologies of potential users of a palliative care information system.

Methods: The Task, User, Representation, Functionality (TURF) framework was applied to characterize potential users (patients and caregivers) of an information system for palliative care in a private clinic in Medellin, Colombia, through a survey.

Results: We analyzed 35 patients and 39 caregivers. The majority were women, that lived in urban area and belonged to middle-income socioeconomic stratum. Caregivers, in contrast to patients, are common users of information and communication technologies.

Conclusion: An information system should focus on the needs of caregivers, and it would be targeted to subjects facing challenges related to technology adoption; information and communication technologies are interesting and important tools for the improvement of health team.
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October 2018

Measuring Workload Demand of Informatics Systems with the Clinical Case Demand Index.

AMIA Annu Symp Proc 2017 16;2017:985-993. Epub 2018 Apr 16.

Center for Biomedical Informatics, College of Medicine, Texas A&M Health Science Center, Houston, TX, USA.

The increasing use of Health Information Technology (HIT) can add substantially to workload on clinical providers. Current methods for assessing workload do not take into account the nature of clinical cases and the use of HIT tools while solving them. The Clinical Case Demand Index (CCDI), consisting of a summary score and visual representation, was developed to meet this need. Consistency with current perceived workload measures was evaluated in a Randomized Control Trial of a mobile health system. CCDI is significantly correlated with existing workload measures and inversely related to provider performance. CCDI combines subjective and objective characteristics of clinical cases along with cognitive and clinical dimensions. Applications include evaluation of HIT tools, clinician scheduling, medical education. CCDI supports comparative effectiveness research of HIT tools. In addition, CCDI could have numerous applications including training, clinical trials, design of clinical workflows, and others.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5977563PMC
March 2019

Rapid Development and Distribution of Mobile Media-Rich Clinical Practice Guidelines Nationwide in Colombia.

Stud Health Technol Inform 2017 ;245:1220

Oficina de Calidad, Ministerio de Salud y de la Protección Social, Colombia.

Development and electronic distribution of Clinical Practice Guidelines production is costly and challenging. This poster presents a rapid method to represent existing guidelines in auditable, computer executable multimedia format. We used a technology that enables a small number of clinicians to, in a short period of time, develop a substantial amount of computer executable guidelines without programming.
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June 2018

Development of a Dynamic and Adaptive Simulator for Health.

Stud Health Technol Inform 2015 ;216:1062

Escuela de Ciencias de la Salud, Universidad Pontificia Bolivariana, Colombia.

One of the ways to develop health simulations is through the use of computers. This paper presents the use of Intelligent Computer-aided Instruction (ICAI) for the development of an interactive simulator for learning Cardio Pulmonary Resucitation (CPR) which incorporates online tutorials, training and evaluation.
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December 2016

Decreasing workload among community health workers using interactive, structured, rich-media guidelines on smartphones.

Technol Health Care 2013 ;21(2):113-23

School of Biomedical Informatics, University of Texas, Houston, TX, USA.

Background: Currently, in developing countries, there is considerable interest in using mobile phones as job-aids for community health workers (CHWs) to improve the care they provide. However, acceptance of new technologies can be inhibited if the workload imposed is perceived as excessive compared to existing methods.

Objective: To compare perceived workload of CHWs using clinical care guidelines presented on mobile phones versus using conventional paper-based guidelines.

Methods: Validated clinical practice guidelines were developed as Interactive Structured Rich-Medical guidelines (ISRMGs) on Windows Mobile 6.5 mobile phones. A prospective randomized controlled study was performed in Colombia in which 50 CHWs used the ISRMGs, and paper-based materials with the same information, in a cross-over design to diagnose and treat 15 matched pairs of medical cases presented on Human Patient simulators. The NASA Task Load Index, a validated measure of perceived workload, was administered and results compared by means of a mixed model analysis.

Results: When using the ISRMGs on mobile phones the health workers reported statistically significant decreases in mental demand, frustration, and overall workload as compared to using paper-based job-aids.

Conclusions: Use of ISRMGs on mobile phones by community health workers in developing countries has the potential to decrease their perceived workload, fatigue, and enhance their ability to provide better care for more patients.
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http://dx.doi.org/10.3233/THC-130713DOI Listing
September 2013

Mosaics versus Early Treatment Diabetic Retinopathy seven standard fields for evaluation of diabetic retinopathy severity.

Retina 2011 Sep;31(8):1553-63

The Department of Ophthalmology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

Purpose: To compare agreement between mosaicked and seven field photographs for classification of the diabetic retinopathy (DR) severity.

Methods: Mosaic digital (MosD) images were compared with seven field stereo film (7FF) and stereo digital (7FD) photographs from a 152-eye cohort with full-spectrum Early Treatment of Diabetic Retinopathy severity levels for agreement on severity level, DR presence with ascending severity thresholds, DR index lesion presence, and classification repeatability.

Results: There was a substantial agreement classifying the Early Treatment Diabetic Retinopathy Study DR severity level between MosD and 7FF (kunweighted = 0.59, klinear weighted = 0.83), MosD and 7FD (κ = 0.62, κ weighted = 0.86), and 7FD and 7FF (κ = 0.62, κ weighted = 0.86) images. Marginal homogeneity analyses found no significant difference between MosD and 7FF (P = 0.44, Bhapkar's test). Kappa between MosD and 7FF ranged from 0.75 to 0.91 for the presence or absence of DR at 8 ascending severity thresholds. Repeatability among readers using MosD images was similar to repeatability among those using 7FF or 7FD. Repeatability among readers using MosD and 7FF images at various severity thresholds was similar. Kappa between MosD and 7FF grading for identifying DR lesions ranged from 0.61 to 1.00.

Conclusion: Mosaic images are generally comparable with standard seven-field photographs for classifying DR severity.
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http://dx.doi.org/10.1097/IAE.0b013e3182084273DOI Listing
September 2011

Comparability of digital photography with the ETDRS film protocol for evaluation of diabetic retinopathy severity.

Invest Ophthalmol Vis Sci 2011 Jul 1;52(7):4717-25. Epub 2011 Jul 1.

School of Biomedical Informatics, University of Texas Health Science Center, Houston, Texas, USA.

Purpose: To evaluate digital photography parameters affecting comparability with the Early Treatment Diabetic Retinopathy Study (ETDRS) film protocol for diabetic retinopathy (DR) severity grading.

Methods: ETDRS protocol photographs and four variations of digital images (uncompressed stereoscopic, compressed stereoscopic, uncompressed monoscopic, and uncompressed monoscopic wide-angle mosaic) of 152 eyes were independently evaluated by using ETDRS classifications. Digital formats were compared to film and each other for agreement on severity level, DR presence at ascending threshold, presence of the DR index lesion, and repeatability of grading. Study parameters included image resolution sufficient to distinguish small lesions, color balancing of digital images to film, documenting essential ETDRS classification retinal regions, similar magnification, and supplementary green-channel viewing.

Results: The κ statistic was substantial or near substantial between all digital formats and film for classifying severity levels (κ = 0.59-0.62; κ(w) [linear weighted] = 0.83-0.87). The distribution of DR levels in all digital formats was not significantly different from that of the film (Bhapkar test, P = 0.09-0.44). The κ among digital formats for severity level was also substantial or near substantial (κ = 0.58-0.76, κ(w) = 0.82-0.92). Differences between digital formats and film for grading severity level, severity threshold, or index lesions were not significant. The repeatability of grading between readers using film and all digital formats was also similar.

Conclusions: Digital format variations compared favorably with film for DR classification. Translating film characteristics (resolution, color/contrast) and protocol (magnification, retinal regions) to digital equivalents and augmentation of full color with green-channel viewing most likely contributed to the results.
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http://dx.doi.org/10.1167/iovs.10-6303DOI Listing
July 2011

Performance factors of mobile rich media job aids for community health workers.

J Am Med Inform Assoc 2011 Mar-Apr;18(2):131-7. Epub 2011 Feb 2.

Faculty of Medicine, University of Antioquia, Medellín, Colombia.

Objective: To study and analyze the possible benefits on performance of community health workers using point-of-care clinical guidelines implemented as interactive rich media job aids on small-format mobile platforms.

Design: A crossover study with one intervention (rich media job aids) and one control (traditional job aids), two periods, with 50 community health workers, each subject solving a total 15 standardized cases per period per period (30 cases in total per subject).

Measurements: Error rate per case and task, protocol compliance.

Results: A total of 1394 cases were evaluated. Intervention reduces errors by an average of 33.15% (p = 0.001) and increases protocol compliance 30.18% (p < 0.001). Limitations Medical cases were presented on human patient simulators in a laboratory setting, not on real patients.

Conclusion: These results indicate encouraging prospects for mHealth technologies in general, and the use of rich media clinical guidelines on cell phones in particular, for the improvement of community health worker performance in developing countries.
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http://dx.doi.org/10.1136/jamia.2010.010025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3116248PMC
July 2011

Grading diabetic retinopathy severity from compressed digital retinal images compared with uncompressed images and film.

Retina 2010 Nov-Dec;30(10):1651-61

Department of Ophthalmology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

Purpose: To compare research grading of diabetic retinopathy (DR) severity level from compressed digital images versus uncompressed images and film.

Methods: Compressed (JPEG2000, 37:1) digital images (C) were compared with uncompressed digital (U) and film (F) stereoscopic photographs from a 152-eye cohort with full-spectrum Early Treatment Diabetic Retinopathy Study severity levels for agreement on severity level, DR presence with ascending severity threshold, presence of DR index lesions, and repeatability of grading.

Results: Classification of Early Treatment Diabetic Retinopathy Study severity levels from C images agreed substantially with results from F images (κ = 0.60, κ(w) [linear weighted] = 0.86) and uncompressed digital images (κ = 0.76, κ(w) = 0.92). For agreement of uncompressed digital versus F images, κ = 0.62 and κ(w) = 0.86. Distribution of Early Treatment Diabetic Retinopathy Study levels was not significantly different between C and F images (P = 0.09, Bhapkar's test for marginal homogeneity). For presence/absence of DR at 8 ascending severity thresholds, agreement between C and F was "almost perfect" (κ ≥ 0.8). Agreement on severity level between readers with C images was at least as good as that with uncompressed digital image or F. Repeatability of severity threshold grading between readers was similar using C or F images. For identifying individual DR lesions, agreement between C and F ranged from "moderate" to "perfect." Agreement of grading venous beading from C was slightly lower than from F.

Conclusion: Full Early Treatment Diabetic Retinopathy Study scale DR severity level grading using C images is comparable to that using U images or film.
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http://dx.doi.org/10.1097/IAE.0b013e3181e3790bDOI Listing
February 2011

Comparison of multiple stereoscopic and monoscopic digital image formats to film for diabetic macular edema evaluation.

Invest Ophthalmol Vis Sci 2010 Dec 23;51(12):6753-61. Epub 2010 Jun 23.

School of Biomedical Informatics, University of Texas Health Science Center, Houston, TX 77004, USA.

Purpose: To assess agreement between evaluations of monoscopic and stereoscopic digital images versus stereo film photographs in diabetic macular edema (DME).

Methods: A 152-eye group of digital monoscopic macular images (seven-field sets and wide-angle mosaics) were compared with digital stereoscopic images (uncompressed and compressed seven-field sets) and stereo 35-mm film photos (Early Treatment Diabetic Retinopathy Study protocol) for the presence of hard exudates (HE), retinal thickening (RT), clinically significant macular edema (CSME), and RT at the center of the macular (RTCM).

Results: Agreement, according to the κ statistic, was almost perfect in identifying HE and RT between all digital formats and stereo film (HE, κ = 0.81-0.87; RT, κ = 0.87-0.92). Distribution in all digital formats was not significantly different from that in film (Bhapkar test: HE, P = 0.20-0.40; RT, P = 0.06-1.0). CSME and RTCM grading differences were either significant or trended toward significance. The readers detected CSME and RTCM in film images more often than in digital formats. In identifying DME features, agreement between evaluations of monoscopic digital formats and film was similar to that between stereo digital formats and film, and the performance of uncompressed images versus film was similar to that of compressed images versus film. Repeatability between readers was similar in evaluations of film and all digital formats. Repeatability in identifying RTCM was lower than that of other DME components in film and all digital formats.

Conclusions: Stereoscopic digital formats are equivalent to monoscopic for DME evaluation, but digital photography is not as sensitive as film in detecting CSME and RTCM.
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http://dx.doi.org/10.1167/iovs.10-5504DOI Listing
December 2010

Digital versus film Fundus photography for research grading of diabetic retinopathy severity.

Invest Ophthalmol Vis Sci 2010 Nov 19;51(11):5846-52. Epub 2010 May 19.

School of Biomedical Informatics, University of Texas Health Science Center, Houston, Texas, USA.

Purpose: To assess agreement between digital and film photography for research classification of diabetic retinopathy severity.

Methods: Digital and film photographs from a 152-eye cohort with a full spectrum of Early Treatment Diabetic Retinopathy Study (ETDRS) severity levels were assessed for repeatability of grading within each image medium and for agreement on ETDRS discrete severity levels, ascending severity thresholds, and presence or absence of diabetic retinopathy index lesions, between digital and 35-mm slides (film). Digital photographs were color balanced to match film.

Results: There was substantial agreement (κ = 0.61, κ(w) [linear weighted] = 0.87) in classification of ETDRS diabetic retinopathy severity levels between digital images and film. Marginal homogeneity analyses found no significant difference in frequency distributions on the severity scale (P = 0.21, Bhapkar test). The κ results ranged from 0.72 to 0.95 for presence or absence of eight ascending diabetic retinopathy severity thresholds. Repeatability of grading between readers viewing digital images was equal to or better than that obtained with film (pair-wise interreader κ for digital images ranged from 0.47 to 0.57 and for film from 0.43 to 0.57. The κ results for identifying diabetic retinopathy lesions ranged from moderate to almost perfect. Moderate agreement of intraretinal microvascular abnormalities and venous beading between digital images and film accounted for slightly lower concordance for severity thresholds ≥47 and for slightly lower interreader agreement within digital and film images at severity thresholds ≥43 and ≥47.

Conclusions: Under controlled circumstances, digital photography can equal the reliability of 35-mm slides for research classification of ETDRS severity level.
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http://dx.doi.org/10.1167/iovs.09-4803DOI Listing
November 2010

Monoscopic versus stereoscopic retinal photography for grading diabetic retinopathy severity.

Invest Ophthalmol Vis Sci 2010 Jun 6;51(6):3184-92. Epub 2010 Jan 6.

Department of Ophthalmology and Visual Sciences, University of Texas Medical Branch, Galveston, Texas 77555-1106, USA.

Purpose: To assess agreement between monoscopic and stereoscopic photography for research classification of the severity of diabetic retinopathy (DR).

Methods: Monoscopic digital (MD) images were compared with stereo digital (SD) and film (SF) photographs from a 152-eye cohort with full-spectrum Early Treatment Diabetic Retinopathy Study (ETDRS) severity levels for agreement on severity level, DR presence with ascending severity threshold, presence of DR index lesions, and repeatability of grading.

Results: There was substantial agreement classifying ETDRS DR severity levels between MD and SF (kappa = 0.65, kappa(w) [linear weighted] = 0.87), MD and SD (kappa = 0.66, kappa(w) = 0.87), and SD and SF (kappa = 0.62, kappa(w) = 0.86) images. Marginal homogeneity analyses found no significant difference between MD and SF images (P = 0.53, Bhapkar test). The kappa agreement between MD and SF ranged from 0.80 to 0.94 for the presence or absence of eight ascending DR severity thresholds. Repeatability between the readers of the MD images was equal to or better than that of the readers of SD or SF images. Severity threshold grading repeatability between readers was similar with the MD and SF images. The kappa agreement between MD and SF for identifying diabetic retinopathy lesions ranged from moderate to almost perfect. The kappa comparisons showed that performance of grading new vessels on the disc in MD images was slightly lower than that with the SF images.

Conclusions: Monoscopic photography can equal the reliability of stereo photography for full ETDRS DR severity scale grading.
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http://dx.doi.org/10.1167/iovs.09-4886DOI Listing
June 2010