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Qualitative Study of Interprofessional Collaboration in Radiation Oncology Clinics: Is There a Need for Further Education?

Interprofessional education (IPE) is gaining recognition as a means of improving health care delivery and patient outcomes. A primary goal of IPE is improved interprofessional collaboration (IPC). The multidisciplinary team in the radiation oncology clinic requires effective IPC for optimal delivery of radiation therapy. However, there are limited data on IPE and IPC in radiation oncology. This qualitative study aims to characterize IPC in radiation oncology.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

Patient rooms transition: Contemporary makes way for the future

Recent advances in lighting research, technology and control systems are creating new opportunities to use lighting in healthcare facilities, particularly patient rooms, to improve everyday experiences for patients, visitors and staff. Healthcare facilities design has undergone shifts in thinking over the past 50 years, including the incorporation of more technology, and moving from an institutional appearance to a residential appearance, with biophilic elements. The Facilities Guidelines Institute defines the term environment of care as “those physical environment features in a health care facility that are created, structured, and maintained to support and enhance the delivery of health care”. Many attributes of the environment of care in existing hospital patient rooms, especially those built prior to 1990, reflect a focus on maximizing the efficiency of delivering medical care, sometimes without much attention to the impact of design on the experience of patients and guests.

Davis, Robert G.↗

Commitment to Hypertension Control During the COVID-19 Pandemic: Million Hearts Initiative Exemplars

Hypertension is a major risk factor for cardiovascular diseases, but 3 of 4 US adults do not have their blood pressure adequately controlled. Million Hearts (US Department of Health and Human Services) is a national initiative that promotes a set of priorities and interventions to optimize delivery of evidence-based strategies to manage cardiovascular disease, including hypertension. The COVID-19 pandemic, however, has disrupted routine care and preventive service delivery. We identified examples of clinical and health organizations that adapted services and care processes to continue a focus on monitoring and controlling hypertension during the pandemic. Eight Hypertension Control Exemplars were identified and interviewed. They reported various adapted care strategies including telemedicine, engaging patients in self-measured blood pressure monitoring, adapting or implementing medication management services, activating partnerships to respond to patient needs or expand services, and implementing unique patient outreach approaches. Documenting these hypertension control strategies can help increase adoption of adaptive approaches during public health emergencies and routine care.

59 BASIC BIOLOGICAL SCIENCES↗

Anomaly Detection in Sequential Health Care Data using Higher-Order Network Representation

The ever-increasing use of information technology (IT) in health care presents new challenges to patient care. Information errors arising from the use of Health IT and their implications on care delivery and patient outcomes have been widely reported. Information errors can lead to changes in clinical decisions, care processes, and care outcomes, among others. An altered care process, for example, could interrupt the sequence of care, which could lead to changes in care decisions and/or changes in care outcomes. We define interruptions in the care process as anomalies in the care sequence. In this paper, we present a new approach based on the higher-order network (HON) representation to detect anomalies in sequential health care data using electronic health records. The results show that there are higher-order dependencies in health care data; and that the use of HON representation is more effective than the first-order network representation for detecting anomalies in sequential health care data.

Niu, Haoran↗

Knowledge of lactation amenorrhea method among postpartum women in Ethiopia: a facility-based cross-sectional study

While the importance of knowledge about contraceptives in improving their utilization and thereby reducing the risk of unintended pregnancies is well documented, there are limited studies documented about the Lactational Amenorrhea Method (LAM). Thus, understanding the knowledge of postpartum mothers about LAM is essential for designing tailored interventions. This study assessed the level of knowledge about LAM and its associated factors among postpartum mothers in Ethiopia. A facility-based cross-sectional study was conducted among 3148 randomly selected postpartum participants. The study utilized multistage sampling approach in hospitals located across five regions and one city administration in Ethiopia. Data were collected using face-to-face interviews at discharge. A participant was categorized as having knowledge of LAM if she correctly answered the three LAM criteria: amenorrhea, the first 6 months, and exclusive breast feeding. A binary logistic regression model was used to identify factors associated with knowledge of LAM. Variables with p < 0.25 in the binary logistic regression were included in the multiple logistic regression. Then, associations were described using the adjusted odds ratio (AOR) along with the 95% confidence interval (CI), and statistical significance was declared at p < 0.05. Only four in 10 participants (40.6%; 95% CI 38.9–42.3) had knowledge of LAM. Participants who attended college or above educational level (AOR = 2.1, 95% CI 1.5–2.8), those with parity of two (AOR = 2.3; 95% CI 1.6–3.6) or more than two (AOR = 2.4; 95% CI 1.5–4.0), those who expressed a desire for further fertility (AOR = 1.3; 95% CI 1.1–1.5), individuals who received counselling on LAM (AOR = 3.0; 95% CI 2.6–3.7), and those who gave birth in hospital (AOR = 2.6; 95% CI 1.4–2.6) had higher odds of knowledge about LAM, compared to their counter parts. In contrary, participants resided far away from health facilities had 30% lower odd of knowledge about LAM compared to those resided near the health facilities (AOR = 0.70; 95% CI 0.6–0.8). The proportion of participants who had knowledge of LAM was low. Strengthening counseling about LAM during antenatal care and delivery with due attention to women with limited access to health facilities should be considered for increasing their level of knowledge on LAM.

60 APPLIED LIFE SCIENCES↗

Development of Employee Health Services Scorecards and Dashboards for Sandia National Laboratories (SAND2020-2243 J)

The mission of Employee Health Services (EHS) at Sandia National Laboratories is to positively and efficiently impact the health of Sandia through patient-centered, cost-effective, community-connected care in support of its mission and people. We strive to continuously improve the delivery of health and wellness services. For the past few years, we have modeled our health programs around findings from the 2010 World Economics Forum (WEF): there are 8 top health risks and behaviors that drive 15 chronic conditions which account for 80% of the total health-care costs for all chronic illness worldwide. The WEF goes on to state that information and innovation are the keys to prevention, and EHS has decided to take a strong stand in both categories by utilizing health scorecards and department dashboards to visualize and share metrics with Sandia Leadership to foster improvements in employee wellness and optimize wellness offerings. Finally, these 2 types of information-sharing tools allow us to track the dollars spent and saved on our wellness programs, and show leadership where there is risk, where there is progress, and where there is need by providing current data that gives monthly, quarterly, and yearly feedback.

60 APPLIED LIFE SCIENCES↗

Determinants of rural-urban differences in health care provider visits among women of reproductive age in the United States

Background Rural health disparities and access gaps may contribute to higher maternal and infant morbidity and mortality. Understanding and addressing access barriers for specialty women’s health services is important in mitigating risks for adverse childbirth events. The objective of this study was to investigate rural-urban differences in health care access for women of reproductive age by examining differences in past-year provider visit rates by provider type, and quantifying the contributing factors to these findings. Methods and findings Using a nationally-representative sample of reproductive age women (n = 37,026) from the Medical Expenditure Panel Survey (2010–2015) linked to the Area Health Resource File, rural-urban differences in past-year office visit rates with health care providers were examined. Blinder-Oaxaca decomposition analysis quantified the portion of disparities explained by individual- and county-level sociodemographic and provider supply characteristics. Overall, there were no rural-urban differences in past-year visits with women’s health providers collectively (65.0% vs 62.4%), however differences were observed by provider type. Rural women had lower past-year obstetrician-gynecologist (OB-GYN) visit rates than urban women (23.3% vs. 26.6%), and higher visit rates with family medicine physicians (24.3% vs. 20.9%) and nurse practitioners/physician assistants (NPs/PAs) (24.6% vs. 16.1%). Lower OB-GYN availability in rural versus urban counties (6.1 vs. 13.7 providers/100,000 population) explained most of the rural disadvantage in OB-GYN visit rates (83.8%), and much of the higher family physician (80.9%) and NP/PA (50.1%) visit rates. Other individual- and county-level characteristics had smaller effects on rural-urban differences. Conclusion Although there were no overall rural-urban differences in past-year visit rates, the lower OB-GYN availability in rural areas appears to affect the types of health care providers seen by women. Whether rural women are receiving adequate specialized women’s health care services, while seeing a different cadre of providers, warrants further investigation and has particular relevance for women experiencing high-risk pregnancies and deliveries.

60 APPLIED LIFE SCIENCES↗

A simulation framework for evaluating electronic order workflows in integrated health records

Electronic health record (EHR) systems are critical to modern healthcare delivery, yet the dynamic workflows that govern electronic order processing remain underexplored. Inefficiencies in these digital pathways can cause delays in care, repetitive workloads, and even patient harm. This study presents a discrete-event simulation framework used to reconstruct and evaluate EHR-based order workflows in a large integrated healthcare system. Using real-world data extracted from the Veterans Health Administration’s Corporate Data Warehouse, the authors mapped order events to standardized state transitions and modeled their progression across different facilities of varying complexity levels. After being calibrated with empirical distributions of transition times and validated against observed time-in-system metrics, the simulation demonstrates close alignment with historical performance. Scenario analyses reveal that resource capacity constraints significantly amplify the impact of electronic order surges, which are reflected in the disproportionate growth in backlogs and processing delays. Adjustments in transition probabilities further increased recirculation and extended workflow paths. Network-based analysis identified Reserved, InProgress, and Completed as structurally critical states that function as hubs within the process network but the transitions in-between also act as major bottlenecks. These results showcased the effectiveness of simulation-based approaches in monitoring EHR order processing performance and evaluating consequences of workflow changes on healthcare network resources planning. The proposed simulation framework provides a scalable data-driven tool to support operational decision-making and improve the efficiency of electronic order management in complex healthcare environments.

Engineering↗

Breathe Well, Live Well: Implementing an Adult Asthma Self-Management Education Program

Asthma remains a significant health problem in the United States. Adults with poorly controlled asthma can affect their community in a number of ways, from lost productivity in the workplace to health care costs to premature death. Asthma self-management education helps individuals achieve better control of their asthma and is critical for the overall health and well-being of individuals with asthma. While there are numerous programs and initiatives targeting children with asthma, there is a lack of comparable focus on the needs of adults with asthma. The American Lung Association developed Breathe Well, Live Well, an adult asthma self-management education program, and launched it nationwide in 2007. The program for adults has a flexible delivery format for community-based implementation. This article describes the development, dissemination, and transformation of the program. Each stage of implementation showed positive changes in asthma self-management practices that contribute to better asthma control, and one local implementation additionally showed decreased reports of missed work and unscheduled health care visits among participants. The findings from the three evaluations support the use of Breathe Well, Live Well for broad community-based implementation to improve asthma self-management efficacy and behaviors.

Gardner, Emily A.↗

Characteristics of Veterans With Depression Who Use the Veterans Choice Program of the Veterans Health Administration

Objective: The Veterans Choice Program (VCP) of the Veterans Health Administration (VHA) allowed eligible veterans to use their benefits with participating providers outside the VHA. The authors aimed to identify characteristics of veterans with depression who used or did not use mental health care through the VCP. Methods: In this cross-sectional study, the authors analyzed secondary data from the national VHA Corporate Data Warehouse. VHA administrative data were linked with VCP claims to examine characteristics of VCP-eligible veterans with depression. Further, the study sample included 595,943 unique veterans who were enrolled in the VHA before 2013, were eligible for the VCP in 2016, were alive in 2018, and had an assessed Patient Health Questionnaire–9 (PHQ-9) score or depressive disorder diagnosis documented in the VHA between 2016 and 2018. Results: Veterans who used the VCP had lower medical comorbidity scores and lived in less socioeconomically disadvantaged counties, compared with veterans who received only VHA care. VCP veterans were also more likely to have a PHQ-9 score assessment and to have higher mean depression scores. Mean counts of annual mental health visits per 1,000 veterans were markedly higher for direct VHA care than for care provided via the VCP. As a percentage of the total counts of visits per 1,000 veterans across the VCP and VHA, residential programs and outpatient procedures were the services that were most frequently delivered through the VCP. Conclusions: Between 2016 and 2018, the VCP was used primarily to augment mental health care provided by the VHA, rather than to fill a gap in care.

60 APPLIED LIFE SCIENCES↗

Sequential Inference of Hospitalization Electronic Health Records Using Probabilistic Models

In the dynamic hospital setting, decision support can be a valuable tool for improving patient outcomes. Data-driven inference of future outcomes is challenging in this dynamic setting, where long sequences such as laboratory tests and medications are updated frequently. This is due in part to heterogeneity of data types and mixed-sequence types contained in variable length sequences. In this work we design a probabilistic unsupervised model for multiple arbitrary-length sequences contained in hospitalization Electronic Health Record (EHR) data. The model uses a latent variable structure and captures complex relationships between medications, diagnoses, laboratory tests, neurological assessments, and medications. It can be trained on original data, without requiring any lossy transformations or time binning. Inference algorithms are derived that use partial data to infer properties of the complete sequences, including their length and presence of specific values. We train this model on data from subjects receiving medical care in the Kaiser Permanente Northern California integrated healthcare delivery system. The results are evaluated against held-out data for predicting the length of sequences and presence of Intensive Care Unit (ICU) in hospitalization bed sequences. Our method outperforms a baseline approach, showing that in these experiments the trained model captures information in the sequences that is informative of their future values.

97 MATHEMATICS AND COMPUTING↗

Unsupervised probabilistic models for sequential Electronic Health Records

We develop an unsupervised probabilistic model for heterogeneous Electronic Health Record (EHR) data. Utilizing a mixture model formulation, our approach directly models sequences of arbitrary length, such as medications and laboratory results. This allows for subgrouping and incorporation of the dynamics underlying heterogeneous data types. The model consists of a layered set of latent variables that encode underlying structure in the data. These variables represent subject subgroups at the top layer, and unobserved states for sequences in the second layer. We train this model on episodic data from subjects receiving medical care in the Kaiser Permanente Northern California integrated healthcare delivery system. The resulting properties of the trained model generate novel insight from these complex and multifaceted data. In addition, we show how the model can be used to analyze sequences that contribute to assessment of mortality likelihood.

59 BASIC BIOLOGICAL SCIENCES↗

Modeling efficient and equitable distribution of COVID-19 vaccines

Producing and distributing COVID-19 vaccine during the pandemic is a major logistical challenge requiring careful planning and efficient execution. This report presents information on logistical, policy and technical issues relevant to rapidly fielding a COVID-19 vaccination program. For this study we (a) conducted literature review and subject matter expert elicitation to understand current vaccine manufacturing and distribution capabilities and vaccine allocation strategies, (b) designed a baseline vaccine distribution strategy and modeling strategy to provide insight into the potential for targeted distribution of limited initial vaccine supplies, and (c) developed parametric interfaces to enable vaccine distribution scenarios to be analyzed in depth with Sandias Adaptive Recovery Model that will allow us evaluate the additional sub- populations and alternative distribution scenarios from a public health benefit and associated economic disruption Principal issues, challenges, and complexities that complicate COVID-19 vaccine delivery identified in our literature and subject matter expert investigation include these items: The United States has not mounted an urgent nationwide vaccination campaign in recent history. The existing global manufacturing and distribution infrastructure are not able to produce enough vaccine for the population immediately. Vaccines, once available will be scarce resources. Prioritization for vaccine allocation will be built on existing distribution networks. Vaccine distribution may not have a universal impact on disease transmission and morbidity because of scarcity, priority population demographics, and underlying disease transmission rates. Considerations for designing a vaccine distribution strategy are discussed. A baseline distribution strategy is designed and tested using the Adaptive Recovery Model, which couples a deterministic compartmental epidemiological model and a stochastic network model. We show the impact of this vaccine distribution strategy on hospitalizations, mortality, and contact tracing requirements. This model can be used to quantitatively evaluate alternative distribution scenarios, guiding policy decisions as vaccine candidates are narrowed down.

59 BASIC BIOLOGICAL SCIENCES↗

Six-Month Outcomes of Infants Born to People With SARS-CoV-2 in Pregnancy

OBJECTIVES To assess the 6-month incidence of laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, postnatal care, hospitalization, and mortality among infants born to people with laboratory-confirmed SARS-CoV-2 infection during pregnancy by timing of maternal infection. METHODS Using a cohort of liveborn infants from pregnancies with SARS-CoV-2 infections in the year 2020 from 10 United States jurisdictions in the Surveillance for Emerging Threats to Mother and Babies Network, we describe weighted estimates of infant outcomes from birth through 6 months of age from electronic health and laboratory records. RESULTS Of 6601 exposed infants with laboratory information through 6 months of age, 1.0% (95% confidence interval: 0.8–1.1) tested positive, 19.1% (17.5–20.6) tested negative, and 80.0% (78.4–81.6) were not known to be tested for SARS-CoV-2. Among those ≤14 days of age, SARS-CoV-2 infection occurred only with maternal infection ≤14 days before delivery. Of 3967 infants with medical record abstraction, breastmilk feeding initiation was lower when maternal infection occurred ≤14 days before delivery compared with >14 days (77.6% [72.5–82.6] versus 88.3% [84.7–92.0]). Six-month all-cause hospitalization was 4.1% (2.0–6.2). All-cause mortality was higher among infants born to people with infection ≤14 days (1.0% [0.4–1.6]) than >14 days (0.3% [0.1–0.5]) before delivery. CONCLUSIONS Results are reassuring, with low incidences of most health outcomes examined. Incidence of infant SARS-CoV-2, breastmilk feeding initiation, and all-cause mortality differed by timing of maternal infection. Strategies to prevent infections and support pregnant people with coronavirus disease 2019 may improve infant outcomes.

Pediatrics↗

The Next Stage for Smart Cities: Metrics to Spur an Evolution from Technology for Efficiency to Technology for People's Needs

The Smart Cities movement is about a decade old, energized by the USDOT Smart Cities grant that sparked cities to dream big. Now, 10 years later, and multitudes of conferences and papers later, the biggest question regarding Smart Cities is whether any progress has been made? Smart Cities forums are typically led by the technology sector, either telecommunications, internet access, or most recently artificial intelligence (AI) concerns. Each of these areas have grown and found new applications in the context of Smart Cities, however, these technology applications are just tools toward ends. Do digital communications and assistance enable or foster improved access to real, tactile, non-virtual goods and services such as transportation, food, housing, trash removal, health care, education, social interaction? These and other topics are not 'big tech', but are each critical to quality of life outcomes and are day-to-day necessities, comprising many of the touch points through which citizens interact with municipal agencies. Regarding Smart Cities, relationships have not been fully refined as to how best to merge the emerging generation of technology and related trends with more mundane but essential requirements of tactile services. How should municipal managers and operators bring the range of new technology tools (e.g. on-demand transit, automated vehicles, digital connectivity) to bear to improve functions serving real- physical- non-virtual needs? How do we make cities more efficient in providing access to services and opportunities for improved quality of life? This paper examines the current Smart City movement, emerging trends, and the need to put metrics with respect to the delivery, access, and provision of real-life needs. Using a few case studies of past, present, and projected future scenarios, this paper attempts to bring Smart Cities into the real cities domain, perhaps pushing the moniker away from 'Smart' to 'Efficient' - something that can be measured, counted, and assessed. Through the consideration of the next stage of the evolution of cities from 'Smart' to 'Efficient', the combined efforts and experience of multiple researchers at the NREL and their network of collaborators highlights the need for updates metrics that can be used to start guiding efforts toward productive initiatives to improve quality of life.

29 ENERGY PLANNING, POLICY, AND ECONOMY↗

Los Alamos National Laboratory Hazardous Waste Facility Permit Community Relations Plan

The requirements of the Hazardous Waste Facility Permit are fulfilled through execution of LANL's fourth strategic goal: “Enabling mission delivery through next-generation facility, infrastructure, and operational excellence.” With input from our stakeholders, we will continue to fulfill those requirements and to improve our waste operations. In 2015, the Laboratory purpose statement focused waste management efforts by directing delivery of mission success through operational effectiveness and scientific excellence. This Plan advances that purpose through community involvement. In the process of achieving our national security mission, Los Alamos National Laboratory generates some hazardous and mixed waste. Hazardous waste is solid waste that is dangerous or potentially harmful to human health or the environment. Hazardous wastes can be liquids, solids, gases, or sludges. They can be discarded as commercial products, such as cleaning fluids or pesticides, or as the byproducts of operations. Specific substances are listed in 40 Code of Federal Regulations (CFR), Part 261: 40 CFR Part 261. Hazardous waste management activities are regulated by the U. S. Environmental Protection Agency and the New Mexico Environment Department (NMED) pursuant to New Mexico Hazardous Waste Act (HWA; Chapter 74, Article 4 NMSA 1978) and regulations under the Act. In 1989, NMED issued the Hazardous Waste Facility Permit (EPA ID Number NM0890010515-1) that established standards for the Laboratory to manage, store, and treat hazardous wastes on-site and to undertake the closure, post closure care, and cleanup as necessary, of permitted waste management units. On November 30, 2010, NMED renewed the Hazardous Waste Facility Permit (the Permit). In June 2020 the Permittees submitted a permit renewal application to the NMED for their review and approval. The Hazardous Waste Facility Permit Community Relations Plan (CRP) describes the scope of public involvement in the activities of the Permit. The CRP is specifically designed to facilitate the community outreach, engagement, and relations activities concerning the Laboratory’s Hazardous Waste Facility Permit and coordinates with but does not include public involvement for other Laboratory programs, initiatives, or environmental activities.

12 MANAGEMENT OF RADIOACTIVE AND NON-RADIOACTIVE W↗

Valuing Resilience for Microgrids: Challenges, Innovative Approaches, and State Needs

The United States depends on the delivery of reliable, affordable, clean, and safe electricity. Electric utilities invest billions of dollars each year in generation, transmission, and distribution assets to meet this need. However, experiences with recent natural disasters of increasing frequency and duration demonstrate the shortcomings of this approach in the face of modern threats. Further, as customers rely on electricity for a broader range of important needs, such as transportation, as well as critical life-saving services and mission critical facilities such as water treatment, medical care, shelters, telecommunications, and more, the need to minimize the likelihood and impacts of outages grows. Against this backdrop, resilience has emerged as a key consideration to guide electricity spending, whether from utilities, customers, or taxpayers. Although reliability has been defined and measured for decades with broadly accepted metrics that measure how many customers lose power and at what frequency and duration, resilience considers the electricity system’s response to a disruption and its subsequent impacts on customers. Developing tools and methods to accurately assess the costs and benefits of resilience investments is a critical step toward the goal of mitigating the impacts of outages on customers and society. Today, electric system resilience is largely treated as an externality due to challenges estimating the costs of long-duration outages, impacts of outages on society, and increasing reliance on electricity for a growing set of interdependent services. These interdependencies include the water, wastewater, telecommunications, natural gas, and health sectors. Without knowing how much a given resilience investment will benefit customers or society more broadly, investors, policymakers, and regulators are less likely to make or approve such investments, and less able to prioritize those investments. State Energy Offices and public utility commissions (PUCs) lead the development of state-level energy policy and utility regulation, respectively, and each has interests in encouraging appropriate public and private investments in resilience. To this end, the National Association of State Energy Officials (NASEO) and National Association of Regulatory Utility Commissioners (NARUC), with the support of the U.S. Department of Energy (DOE) Office of Electricity (OE), formed a joint Microgrids State Working Group to explore the costs and benefits of microgrids, barriers to broader deployment of microgrids to meet resilience and other objectives, and policy and regulatory strategies to optimize investments in resilience, including but not limited to microgrids. Although no universally accepted valuation tool for resilience exists, National Laboratories, utilities, researchers, and state and federal agencies have collaborated to develop, apply, and improve a number of approaches to quantify resilience, several of which are still in progress at the time this report is published. This report seeks to share these important advances by discussing current definitions of resilience (Section 1), how microgrids are defined and used to meet resilience objectives (Section 2), new approaches to valuing resilience (Section 3), steps State Energy Offices and PUCs have taken to further resilience valuation efforts (Section 4), and finally, considerations and suggested next steps for State Energy Offices and PUCs (Section 5). Relevant examples of specific microgrid projects and resilience valuation efforts are included throughout the report. While this report is written specifically for NASEO and NARUC members, it may be useful for utilities, local governments, and individual customers interested in improving the way public and private dollars are spent to achieve resilience outcomes.

24 POWER TRANSMISSION AND DISTRIBUTION↗