text:
Clinical Focus
- Pediatrics
- Pediatric Hospital Medicine
Academic Appointments
Clinical Professor, Pediatrics - Systems Medicine
Clinical Professor, Pediatrics
Clinical Professor (By courtesy), Medicine - Biomedical Informatics Research
Administrative Appointments
Physician Lead, Clinical Informatics, Stanford Children's Health (2004 - 2007)
Medical Director, Clinical Informatics, Stanford Children's Health (2007 - 2010)
Chief Medical Information Officer, Stanford Children's Health (2010 - Present)
VP of Analytics, Stanford Children's Health (2012 - Present)
Fellowship Director, Clinical Informatics, Stanford University Medical Center (2014 - Present)
Honors & Awards
Faculty Fellows Leadership Program, Stanford University School of Medicine (2010)
Top 25 Clinical Informaticist, Modern Healthcare (2010, 2011, 2012)
Letter of Teaching Distinction, Stanford University School of Medicine, Office of the Dean (2011, 2012, 2013)
Professional Education
Board Certification: Clinical Informatics, American Board of Preventive Medicine (2014)
Board Certification: Pediatrics, American Board of Pediatrics (2004)
Residency:Stanford University School of Medicine (2004) CA
Internship:Stanford University School of Medicine (2002) CA
Medical Education:UC Davis School of Medicine (2001) CA
M.S., UC Davis, Medical Informatics (2000)
B.S., UC San Diego, Molecular Biology (1996)
Community and International Work
Faculty Consultant
Partnering Organization(s)
Vermont Oxford Network
Ongoing Project
Opportunities for Student Involvement
Roatan Volunteer Pediatric Clinic, Honduras
Partnering Organization(s)
Global Healing
Populations Served
Latino, Carribean Garifuna
Ongoing Project
Opportunities for Student Involvement
Current Research and Scholarly Interests
Clinical Informatics is the scientific field concerned with the application of information technology to the delivery of healthcare services. In my administrative role as Chief Medical Information Officer (CMIO) at Stanford Children's Health, I oversee the Clinical Informatics and Analytics departments. I am responsible for the implementation and optimization of a comprehensive electronic medical record (EMR) system including computerized physician order entry (CPOE) with clinical decision support (CDS), patient-engaging technologies like personal health records (PHR), and our enterprise data warehouse (EDW).
Together with colleagues in the department, our applied informatics research focuses on rigorously evaluating the best ways to implement and optimize health information technology to benefit the patients we serve at Stanford Children's Health. Specific areas of focus include 1) the impact of health IT on pediatric and obstetric quality/safety 2) advancing clinical decision support through closed-loop analytics, and 3) the intersection of health IT and medical education. Results of this work have been published in peer-reviewed journals like the New England Journal of Medicine, BMJ, Pediatrics, and Applied Clinical Informatics.
Clinical Informatics Fellowship, Stanford University Medical Center
Stanford, CA
- Natalie Pageler, Clinical Assistant Professor, Pediatrics - Critical Care; Associate Program Director, School of Medicine
- Jonathan Palma, Clinical Assistant Professor, Pediatrics - Neonatal and Developmental Medicine, School of Medicine
- Christopher Sharp, Clinical Associate Professor, Medicine - General Medical Disciplines, School of Medicine
- Pravene Nath, Clinical Assistant Professor (Affiliated) , Surgery - Emergency Medicine, School of Medicine
- Todd Ferris, Associate CIO, SoM - Information Resources & Technology, School of Medicine
For More Information:
2015-16 Courses
Independent Studies (8)
- Biomedical Informatics Teaching Methods
BIOMEDIN 290 (Aut)
- Directed Reading and Research
BIOMEDIN 299 (Aut)
- Directed Reading in Pediatrics
PEDS 299 (Aut, Win, Spr)
- Early Clinical Experience
PEDS 280 (Aut, Win, Spr)
- Graduate Research
PEDS 399 (Aut, Win, Spr)
- Medical Scholars Research
BIOMEDIN 370 (Aut)
- Medical Scholars Research
PEDS 370 (Aut, Win, Spr)
- Undergraduate Directed Reading/Research
PEDS 199 (Aut, Win, Spr)
- Biomedical Informatics Teaching Methods
Prior Year Courses
2014-15 Courses
- Clinical Informatics Literature Review Seminar
BIOMEDIN 208 (Win)
- Clinical Informatics Literature Review Seminar
Graduate and Fellowship Programs
Biomedical Informatics (Phd Program)
All Publications
Bordetella petrii Sinusitis in an Immunocompromised Adolescent.
Pediatric infectious disease journal
2015; 34 (4): 458-?
View details for DOI 10.1097/INF.0000000000000564
View details for PubMedID 25760569
AKI in Hospitalized Children: Comparing the pRIFLE, AKIN, and KDIGO Definitions
2015; 10 (4): 554-561
Although several standardized definitions for AKI have been developed, no consensus exists regarding which to use in children. This study applied the Pediatric RIFLE (pRIFLE), AKI Network (AKIN), and Kidney Disease Improving Global Outcomes (KDIGO) criteria to an anonymized cohort of hospitalizations extracted from the electronic medical record to compare AKI incidence and outcomes in intensive care unit (ICU) and non-ICU pediatric populations.Observational, electronic medical record-enabled study of 14,795 hospitalizations at the Lucile Packard Children's Hospital between 2006 and 2010. AKI and AKI severity stage were defined by the pRIFLE, AKIN, and KDIGO definitions according to creatinine change criteria; urine output criteria were not used. The incidences of AKI and each AKI stage were calculated for each classification system. All-cause, in-hospital mortality and total hospital length of stay (LOS) were compared at each subsequent AKI stage by Fisher exact and Kolmogorov-Smirnov tests, respectively.AKI incidences across the cohort according to pRIFLE, AKIN, and KDIGO were 51.1%, 37.3%, and 40.3%. Mortality was higher among patients with AKI across all definitions (pRIFLE, 2.3%; AKIN, 2.7%; KDIGO, 2.5%; P<0.001 versus no AKI [0.8%-1.0%]). Within the ICU, pRIFLE, AKIN, and KDIGO demonstrated progressively higher mortality at each AKI severity stage; AKI was not associated with mortality outside the ICU by any definition. Both in and outside the ICU, AKI was associated with significantly higher LOS at each AKI severity stage across all three definitions (P<0.001). Definitions resulted in differences in diagnosis and staging of AKI; staging agreement ranged from 76.7% to 92.5%.Application of the three definitions led to differences in AKI incidence and staging. AKI was associated with greater mortality and LOS in the ICU and greater LOS outside the ICU. All three definitions demonstrated excellent interstage discrimination. While each definition offers advantages, these results underscore the need to adopt a single, universal AKI definition.
View details for DOI 10.2215/CJN.01900214
View details for Web of Science ID 000352463400005
View details for PubMedID 25649155
Patient and Family Access to Electronic Health Records: A Key Ingredient for a Pediatric Learning Health System.
Journal of participatory medicine
; 7
View details for PubMedID 25664199
Special requirements for electronic medical records in neurology.
Neurology. Clinical practice
2015; 5 (1): 67-73
Electronic medical records (EMRs) are being rapidly adapted in the United States with goals of improving patient care, increasing efficiency, and reducing costs. Neurologists must become knowledgeable about the utility and effectiveness of the important parts of these systems specifically needed for care of neurology patients. The field of neurology encompasses complex disorders whose diagnosis and management heavily relies on detailed medical documentation of history and physical examination, and often on specialty-specific ancillary tests and extensive neuroimaging. Small discrepancies in documentation or absence of an in-hand ancillary test result can drastically change the current workup or treatment decision of a complex patient with neurologic disease. We describe current models and opportunities for improvements to EMRs that provide utility and efficiency in the care of neurology patients.
View details for DOI 10.1212/CPJ.0000000000000093
View details for PubMedID 25717421
Clinical Informatics Fellowship Programs: In Search of a Viable Financial Model: An open letter to the Centers for Medicare and Medicaid Services.
Applied clinical informatics
2015; 6 (2): 267-70
In the US, the new subspecialty of Clinical Informatics focuses on systems-level improvements in care delivery through the use of health information technology (HIT), data analytics, clinical decision support, data visualization and related tools. Clinical informatics is one of the first subspecialties in medicine open to physicians trained in any primary specialty. Clinical Informatics benefits patients and payers such as Medicare and Medicaid through its potential to reduce errors, increase safety, reduce costs, and improve care coordination and efficiency. Even though Clinical Informatics benefits patients and payers, because GME funding from the Centers for Medicare and Medicaid Services (CMS) has not grown at the same rate as training programs, the majority of the cost of training new Clinical Informaticians is currently paid by academic health science centers, which is unsustainable. To maintain the value of HIT investments by the government and health care organizations, we must train sufficient leaders in Clinical Informatics. In the best interest of patients, payers, and the US society, it is therefore critical to find viable financial models for Clinical Informatics fellowship programs. To support the development of adequate training programs in Clinical Informatics, we request that the Centers for Medicare and Medicaid Services (CMS) issue clarifying guidance that would allow accredited ACGME institutions to bill for clinical services delivered by fellows at the fellowship program site within their primary specialty.
View details for DOI 10.4338/ACI-2015-03-IE-0030
View details for PubMedID 26171074
An Exponential Increase in Regional Health Information Exchange With Collaborative Policies and Technologies.
Studies in health technology and informatics
2015; 216: 931-?
In the United States, the ability to securely exchange health information between organization has been limited by technical interoperability, patient identity matching, and variable institutional policies. Here, we examine the regional experience in a national health information exchange network by examining clinical data sharing between eleven Northern California organizations using the same health information exchange (HIE) platform between 2013-2014. We identify key policies and technologies that have led to a dramatic increase in health information exchange.
View details for PubMedID 26262233
Implementation of Data Drive Heart Rate and Respiratory Rate parameters on a Pediatric Acute Care Unit.
Studies in health technology and informatics
2015; 216: 918-?
The majority of hospital physiologic monitor alarms are not clinically actionable and contribute to alarm fatigue. In 2014, The Joint Commission declared alarm safety as a National Patient Safety Goal and urged prompt action by hospitals to mitigate the issue [1]. It has been demonstrated that vital signs in hospitalized children are quite different from currently accepted reference ranges [2]. Implementation of data-driven, age stratified vital sign parameters (Table 1) for alarms in this patient population could reduce alarm frequency.
View details for PubMedID 26262220
Bringing cohort studies to the bedside: framework for a 'green button' to support clinical decision-making.
Journal of comparative effectiveness research
2015: 1-7
When providing care, clinicians are expected to take note of clinical practice guidelines, which offer recommendations based on the available evidence. However, guidelines may not apply to individual patients with comorbidities, as they are typically excluded from clinical trials. Guidelines also tend not to provide relevant evidence on risks, secondary effects and long-term outcomes. Querying the electronic health records of similar patients may for many provide an alternate source of evidence to inform decision-making. It is important to develop methods to support these personalized observational studies at the point-of-care, to understand when these methods may provide valid results, and to validate and integrate these findings with those from clinical trials.
View details for DOI 10.2217/cer.15.12
View details for PubMedID 25959863
The Value of Clinical Teachers for EMR Implementations and Conversions.
Applied clinical informatics
2015; 6 (1): 75-79
Effective physician training is an essential aspect of EMR implementation. However, it can be challenging to find instructors who can present the material in a clinically relevant manner. The authors describe a unique physician-training program, utilizing medical students as course instructors. This approach resulted in high learner satisfaction rates and provided significant cost-savings compared to alternative options.
View details for DOI 10.4338/ACI-2014-09-IE-0075
View details for PubMedID 25848414
Successful Physician Training Program for Large Scale EMR Implementation
2015; 6 (1): 80-95
End-user training is an essential element of electronic medical record (EMR) implementation and frequently suffers from minimal institutional investment. In addition, discussion of successful EMR training programs for physicians is limited in the literature. The authors describe a successful physician-training program at Stanford Children's Health as part of a large scale EMR implementation. Evaluations of classroom training, obtained at the conclusion of each class, revealed high physician satisfaction with the program. Free-text comments from learners focused on duration and timing of training, the learning environment, quality of the instructors, and specificity of training to their role or department. Based upon participant feedback and institutional experience, best practice recommendations, including physician engagement, curricular design, and assessment of proficiency and recognition, are suggested for future provider EMR training programs. The authors strongly recommend the creation of coursework to group providers by common workflow.
View details for DOI 10.4338/ACI-2014-09-CR-0076
View details for Web of Science ID 000354618300002
A 'Green Button' For Using Aggregate Patient Data At The Point Of Care
2014; 33 (7): 1229-1235
Randomized controlled trials have traditionally been the gold standard against which all other sources of clinical evidence are measured. However, the cost of conducting these trials can be prohibitive. In addition, evidence from the trials frequently rests on narrow patient-inclusion criteria and thus may not generalize well to real clinical situations. Given the increasing availability of comprehensive clinical data in electronic health records (EHRs), some health system leaders are now advocating for a shift away from traditional trials and toward large-scale retrospective studies, which can use practice-based evidence that is generated as a by-product of clinical processes. Other thought leaders in clinical research suggest that EHRs should be used to lower the cost of trials by integrating point-of-care randomization and data capture into clinical processes. We believe that a successful learning health care system will require both approaches, and we suggest a model that resolves this escalating tension: a "green button" function within EHRs to help clinicians leverage aggregate patient data for decision making at the point of care. Giving clinicians such a tool would support patient care decisions in the absence of gold-standard evidence and would help prioritize clinical questions for which EHR-enabled randomization should be carried out. The privacy rule in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 may require revision to support this novel use of patient data.
View details for DOI 10.1377/hlthaff.2014.0099
View details for Web of Science ID 000340469700017
View details for PubMedID 25006150
Optimizing Care of Adults With Congenital Heart Disease in a Pediatric Cardiovascular ICU Using Electronic Clinical Decision Support
2014; 15 (5): 428-434
The optimal location for postoperative cardiac care of adults with congenital heart disease is controversial. Some congenital heart surgeons operate on these adults in children's hospitals with postoperative care provided by pediatric critical care teams who may be unfamiliar with adult national performance measures. This study tested the hypothesis that Clinical Decision Support tools integrated into the clinical workflow would facilitate improved compliance with The Joint Commission Surgical Care Improvement Project performance measures in adults recovering from cardiac surgery in a children's hospital.Retrospective chart review comparing compliance pre- and post-Clinical Decision Support intervention for Surgical Care Improvement Project measures addressed in the critical care unit: appropriate cessation of prophylactic antibiotics; controlled blood glucose; urinary catheter removal; and reinitiation of preoperative β-blocker when indicated.Cardiovascular ICU in a quaternary care freestanding children's hospital.The cohort included 114 adults 18-70 years old recovering from cardiac surgery in our pediatric cardiovascular ICU.Clinical Decision Support tools including data-triggered alerts, smart documentation forms, and order sets with conditional logic were integrated into the workflow.Compliance with antibiotic discontinuation was 100% pre- and postintervention. Compliance rates improved for glucose control (p = 0.007) and urinary catheter removal (p = 0.05). Documentation of β-blocker therapy (nonexistent preintervention) was 100% postintervention. Composite compliance for all measures increased from 53% to 84% (p = 0.002). There were no complications related to institution of the Surgical Care Improvement Project measures. There was no in-hospital mortality.Compliance with the national adult postoperative performance measures can be excellent in a children's hospital with the help of Clinical Decision Support tools. This represents an important step toward providing high-quality care to a growing population of adults with congenital heart disease who may receive care in a pediatric center.
View details for DOI 10.1097/PCC.0000000000000124
View details for Web of Science ID 000337368600010
View details for PubMedID 24732291
Use of electronic medical record-enhanced checklist and electronic dashboard to decrease CLABSIs.
2014; 133 (3): e738-46
We hypothesized that a checklist enhanced by the electronic medical record and a unit-wide dashboard would improve compliance with an evidence-based, pediatric-specific catheter care bundle and decrease central line-associated bloodstream infections (CLABSI).We performed a cohort study with historical controls that included all patients with a central venous catheter in a 24-bed PICU in an academic children's hospital. Postintervention CLABSI rates, compliance with bundle elements, and staff perceptions of communication were evaluated and compared with preintervention data.CLABSI rates decreased from 2.6 CLABSIs per 1000 line-days before intervention to 0.7 CLABSIs per 1000 line-days after intervention. Analysis of specific bundle elements demonstrated increased daily documentation of line necessity from 30% to 73% (P < .001), increased compliance with dressing changes from 87% to 90% (P = .003), increased compliance with cap changes from 87% to 93% (P < .001), increased compliance with port needle changes from 69% to 95% (P < .001), but decreased compliance with insertion bundle documentation from 67% to 62% (P = .001). Changes in the care plan were made during review of the electronic medical record checklist on 39% of patient rounds episodes.Use of an electronic medical record-enhanced CLABSI prevention checklist coupled with a unit-wide real-time display of adherence was associated with increased compliance with evidence-based catheter care and sustained decrease in CLABSI rates. These data underscore the potential for computerized interventions to promote compliance with proven best practices and prevent patient harm.
View details for DOI 10.1542/peds.2013-2249
View details for PubMedID 24567021
Core Drug-Drug Interaction Alerts for Inclusion in Pediatric Electronic Health Records With Computerized Prescriber Order Entry
2014; 10 (1): 59-63
The study aims to develop a core set of pediatric drug-drug interaction (DDI) pairs for which electronic alerts should be presented to prescribers during the ordering process.A clinical decision support working group composed of Children's Hospital Association (CHA) members was developed. CHA Pharmacists and Chief Medical Information Officers participated.Consensus was reached on a core set of 19 DDI pairs that should be presented to pediatric prescribers during the order process.We have provided a core list of 19 high value drug pairs for electronic drug-drug interaction alerts to be recommended for inclusion as high value alerts in prescriber order entry software used with a pediatric patient population. We believe this list represents the most important pediatric drug interactions for practical implementation within computerized prescriber order entry systems.
View details for DOI 10.1097/PTS.0000000000000050
View details for Web of Science ID 000335830300008
View details for PubMedID 24522227
Refocusing medical education in the EMR era.
JAMA-the journal of the American Medical Association
2013; 310 (21): 2249-2250
View details for DOI 10.1001/jama.2013.282326
View details for PubMedID 24302083
Association between Maintenance Fluid Tonicity and Hospital-Acquired Hyponatremia
2013; 163 (6): 1646-1651
To evaluate whether the administration of hypotonic fluids compared with isotonic fluids is associated with a greater risk for hyponatremia in hospitalized children.Informatics-enabled cohort study of all hospitalizations at Lucile Packard Children's Hospital between April 2009 and March 2011. Extraction and analysis of electronic medical record data identified normonatremic hospitalized children who received either hypotonic or isotonic intravenous maintenance fluids upon admission. The primary exposure was the administration of hypotonic maintenance fluids, and the primary outcome was the development of hyponatremia (serum sodium <135 mEq/L).A total of 1048 normonatremic children received either hypotonic (n = 674) or isotonic (n = 374) maintenance fluids upon admission. Hyponatremia developed in 260 (38.6%) children who received hypotonic fluids and 104 (27.8%) of those who received isotonic fluids (unadjusted OR 1.63; 95% CI 1.24-2.15, P < .001). After we controlled for intergroup differences and potential confounders, patients receiving hypotonic fluids remained more likely to develop hyponatremia (aOR 1.37, 95% CI 1.03-1.84). Multivariable analysis identified additional factors associated with the development of hyponatremia, including surgical admission (aOR 1.44, 95% CI 1.09-1.91), cardiac admitting diagnosis (aOR 2.08, 95% CI 1.34-3.20), and hematology/oncology admitting diagnosis (aOR 2.37, 95% CI 1.74-3.25).Hyponatremia was common regardless of maintenance fluid tonicity; however, the administration of hypotonic maintenance fluids compared with isotonic fluids was associated with a greater risk of developing hospital-acquired hyponatremia. Additional clinical characteristics modified the hyponatremic effect of hypotonic fluid, and it is possible that optimal maintenance fluid therapy now requires a more individualized approach.
View details for DOI 10.1016/j.jpeds.2013.07.020
View details for Web of Science ID 000327543200025
Medical Education in the Electronic Medical Record (EMR) Era: Benefits, Challenges, and Future Directions
2013; 88 (6): 753-757
View details for DOI 10.1097/ACM.0b013e3182905ceb
View details for Web of Science ID 000319658500011
A Clinical Case of Electronic Health Record Drug Alert Fatigue: Consequences for Patient Outcome
View details for DOI 10.1542/peds.2012-3252
View details for Web of Science ID 000322840200033
Embedding Time-Limited Laboratory Orders Within Computerized Provider Order Entry Reduces Laboratory Utilization
2013; 14 (4): 413-419
: To test the hypothesis that limits on repeating laboratory studies within computerized provider order entry decrease laboratory utilization.: Cohort study with historical controls.: A 20-bed PICU in a freestanding, quaternary care, academic children's hospital.: This study included all patients admitted to the pediatric ICU between January 1, 2008, and December 31, 2009. A total of 818 discharges were evaluated prior to the intervention (January 1, 2008, through December 31, 2008) and 1,021 patient discharges were evaluated postintervention (January 1, 2009, through December 31, 2009).: A computerized provider order entry rule limited the ability to schedule repeating complete blood cell counts, chemistry, and coagulation studies to a 24-hour interval in the future. The time limit was designed to ensure daily evaluation of the utility of each test.: Initial analysis with t tests showed significant decreases in tests per patient day in the postintervention period (complete blood cell counts: 1.5 ± 0.1 to 1.0 ± 0.1; chemistry: 10.6 ± 0.9 to 6.9 ± 0.6; coagulation: 3.3 ± 0.4 to 1.7 ± 0.2; p < 0.01, all variables vs. preintervention period). Even after incorporating a trend toward decreasing laboratory utilization in the preintervention period into our regression analysis, the intervention decreased complete blood cell counts (p = 0.007), chemistry (p = 0.049), and coagulation (p = 0.001) tests per patient day.: Limits on laboratory orders within the context of computerized provider order entry decreased laboratory utilization without adverse affects on mortality or length of stay. Broader application of this strategy might decrease costs, the incidence of iatrogenic anemia, and catheter-associated bloodstream infections.
View details for DOI 10.1097/PCC.0b013e318272010c
View details for Web of Science ID 000318680000016
View details for PubMedID 23439456
Immunization registries in the EMR Era.
Online journal of public health informatics
2013; 5 (2): 211-?
The CDC established a national objective to create population-based tracking of immunizations through regional and statewide registries nearly 2 decades ago, and these registries have increased coverage rates and reduced duplicate immunizations. With increased adoption of commercial electronic medical records (EMR), some institutions have used unidirectional links to send immunization data to designated registries. However, access to these registries within a vendor EMR has not been previously reported.To develop a visually integrated interface between an EMR and a statewide immunization registry at a previously non-reporting hospital, and to assess subsequent changes in provider use and satisfaction.A group of healthcare providers were surveyed before and after implementation of the new interface. The surveys addressed access of the California Immunization Registry (CAIR), and satisfaction with the availability of immunization information. Information Technology (IT) teams developed a "smart-link" within the electronic patient chart that provides a single-click interface for visual integration of data within the CAIR database.Use of the tool has increased in the months since its initiation, and over 20,000 new immunizations have been exported successfully to CAIR since the hospital began sharing data with the registry. Survey data suggest that providers find this tool improves workflow and overall satisfaction with availability of immunization data. (p=0.009).Visual integration of external registries into a vendor EMR system is feasible and improves provider satisfaction and registry reporting.
View details for DOI 10.5210/ojphi.v5i2.4696
View details for PubMedID 23923096
Using an Evidence-Based Approach to EMR Implementation to Optimize Outcomes and Avoid Unintended Consequences.
Journal of healthcare information management : JHIM
2013; 27 (3): 79-83
Implementation of an electronic medical record (EMR) with computerized physician order entry (CPOE) can provide an important foundation for preventing harm and improving outcomes. Incentivized by the recent economic stimulus initiative, healthcare systems are implementing vendor-based EMR systems at an unprecedented rate. Accumulating evidence suggests that local implementation decisions, rather than the specific EMR product or technology selected, are the primary drivers of the quality improvement performance of these systems. However, limited attention has been paid to effective approaches to EMR implementation. In this case report, we outline the evidence-based approach we used to make EMR implementation decisions in a pragmatic structure intended for replication at other sites.
View details for PubMedID 24771994
Rights and responsibilities of electronic health records (EHR) users caring for children.
Archivos argentinos de pediatria
2013; 111 (6)
View details for PubMedID 24196758
Reducing Mortality Related to Adverse Events in Children
2012; 59 (6): 1293-?
Since the launch of the 100,000 Lives Campaign by the Institute for Healthcare Improvement (IHI), preventing medical adverse events to reduce avoidable mortality has emerged as a central focus for health care providers, institutions, regulators, insurance companies, and patients. Evidence-based interventions targeting the 6 interventions in the campaign have been associated with a reduction in preventable hospital deaths in the United States. The generalizability of the IHI's campaign to the pediatric population is only partly applicable. Pediatric experiences with rapid response teams and preventing central-line infections parallel the published experience of adults, with promise to significantly reduce preventable pediatric mortality.
View details for DOI 10.1016/j.pcl.2012.09.002
View details for Web of Science ID 000312618600007
View details for PubMedID 23116526
Special Requirements for Electronic Medical Records in Adolescent Medicine
2012; 51 (5): 409-414
Adolescents are a group likely to seek and, perhaps, most likely to benefit from electronic access to health information. Despite significant advances in technical capabilities over the past decade, to date neither electronic medical record vendors nor many health care systems have adequately addressed the functionality and process design considerations needed to protect the confidentiality of adolescent patients in an electronic world. We propose a shared responsibility for creating the necessary tools and processes to maintain the adolescent confidentiality required by most states: (1) system vendors must provide key functionality in their products (adolescent privacy default settings, customizable privacy controls, proxy access, and health information exchange compatibility), and (2) health care institutions must systematically address relevant adolescent confidentiality policies and process design issues. We highlight the unique technical and process considerations relevant to this patient population, as well as the collaborative multistakeholder work required for adolescent patients to experience the potential benefits of both electronic medical records and participatory health information technology.
View details for DOI 10.1016/j.jadohealth.2012.08.003
View details for Web of Science ID 000310353300002
View details for PubMedID 23084160
Internet Access and Attitudes Toward Online Personal Health Information Among Detained Youth
2012; 130 (5): 914-917
To assess Internet access and usage patterns among high-risk youth involved in the juvenile justice system, and to determine if health information technology tools might play a useful role in more actively engaging this population in their health care.A sample of 79 youth between the ages of 13 and 18 years old underwent a structured interview while detained in a large, Northern California juvenile detention facility. After an institutional review board-approved assent/consent process, youth discussed their typical Internet use when not detained, as well as their attitudes toward online access to their personal health information (PHI).Detained youth from predominantly underserved, minority communities, reported high levels of access to the Internet while outside of the detention setting, with 97% reporting using the Internet at least once per month and 87% at least weekly. Furthermore, 90% of these youth expressed interest in accessing their PHI online and sharing it with either parents or physicians.Detained adolescents describe unexpectedly high usage of the Internet and online resources when they are outside of the juvenile hall setting. These youth show an interest in, and may benefit from, accessing their PHI online. Further studies are needed to understand the potential health benefits that may be realized by engaging this population through online tools.
View details for DOI 10.1542/peds.2012-1653
View details for Web of Science ID 000310505900061
View details for PubMedID 23090346
Integrating the home management plan of care for children with asthma into an electronic medical record.
Joint Commission journal on quality and patient safety / Joint Commission Resources
2012; 38 (8): 359-365
Asthma exacerbation is one of the most common causes for pediatric hospitalization. One of the three Joint Commission quality measures--which has proven the most challenging--addresses the provision of a home management plan of care (HMPC) for discharge of pediatric inpatients with a primary diagnosis of asthma. A user-friendly electronic medical record (EMR)-generated HMPC was developed and implemented at Lucile Packard Children's Hospital (LPCH) Palo Alto, California, an HPMC needed to be completed before entry of an inpatient discharge order.A cohort study using historical controls was conducted in 2010-2011. Patients were eligible to receive an HMPC if they were between the ages of 2 and 17 years old at discharge, had a length of stay < 120 days, were not enrolled in clinical trials, and had the primary discharge diagnosis of asthma. These patients were identified by the EMR if this diagnosis was listed in the diagnosis list or problem list or if the asthma admit/discharge order set was initiated.Compliance with the HMPC increased from 65.3% for the 39 months (April 1, 2007-June 30, 2010) before integration of the HMPC into EMR to 93.7% for the 18 months after integration (July 1, 2010, through December 31, 2011); p < .0001. Users of the EMR-integrated HMPC found it to be significantly easier to complete, less time-consuming, and less prone to potential errors or omission.Lessons learned at LPCH included the need for a continuous surveillance and improvement model, which resulted in several iterations of the HMPC; the importance of soliciting user input, which resulted in improvements in work flow; and consistent support from the quality management and information technology departments, which are crucial to eliminating barriers and facilitating improvement.
View details for PubMedID 22946253
Health information technology and patient safety
2012; 344
View details for DOI 10.1136/bmj.e1096
View details for Web of Science ID 000300881600008
View details for PubMedID 22349580
Neonatal Informatics: Optimizing Clinical Data Entry and Display.
2012; 13 (2): 81-85
Displaying the vast amount of clinical data that exist in electronic medical records without causing information overload or interfering with provider thought processes is a challenge. To support the transformation of data into information and knowledge, effective electronic displays must be flexible and guide physicians' thought processes. Applying research from cognitive science and human factors engineering offers promise in improving the electronic display of clinical information. OBJECTIVES: After completing this article, readers should be able to: Appreciate the importance of supporting provider thought processes during both data entry and data review.Recognize that information does not need to be displayed and reviewed in the same way the data are entered.
View details for PubMedID 22557935
Impact of an EMR-Based Daily Patient Update Letter on Communication and Parent Engagement in a Neonatal Intensive Care Unit.
Journal of participatory medicine
2012; 4
To evaluate the impact of using electronic medical record (EMR) data in the form of a daily patient update letter on communication and parent engagement in a level II neonatal intensive care unit (NICU).Parents of babies in a level II NICU were surveyed before and after the introduction of an EMR-generated daily patient update letter, Your Baby's Daily Update (YBDU).Following the introduction of the EMR-generated daily patient update letter, 89% of families reported using YBDU as an information source; 83% of these families found it "very useful", and 96% of them responded that they "always" liked receiving it. Rates of receiving information from the attending physician were not statistically significantly different pre- and post-implementation, 81% and 78%, respectively (p = 1). Though there was no statistically significant improvement in parents' knowledge of individual items regarding the care of their babies, a trend towards statistical significance existed for several items (p <.1), and parents reported feeling more competent to manage information related to the health status of their babies (p =.039).Implementation of an EMR-generated daily patient update letter is feasible, resulted in a trend towards improved communication, and improved at least one aspect of parent engagement-perceived competence to manage information in the NICU.
View details for PubMedID 23730532
Rapid Implementation of Inpatient Electronic Physician Documentation at an Academic Hospital
2012; 3 (2): 175-185
Electronic physician documentation is an essential element of a complete electronic medical record (EMR). At Lucile Packard Children's Hospital, a teaching hospital affiliated with Stanford University, we implemented an inpatient electronic documentation system for physicians over a 12-month period. Using an EMR-based free-text editor coupled with automated import of system data elements, we were able to achieve voluntary, widespread adoption of the electronic documentation process. When given the choice between electronic versus dictated report creation, the vast majority of users preferred the electronic method. In addition to increasing the legibility and accessibility of clinical notes, we also decreased the volume of dictated notes and scanning of handwritten notes, which provides the opportunity for cost savings to the institution.
View details for DOI 10.4338/ACI-2012-02-CR-0003
View details for Web of Science ID 000317183500003
View details for PubMedID 23620718
Neonatal Informatics: Transforming Neonatal Care Through Translational Bioinformatics.
2012; 13 (5): e281-e284
The future of neonatal informatics will be driven by the availability of increasingly vast amounts of clinical and genetic data. The field of translational bioinformatics is concerned with linking and learning from these data and applying new findings to clinical care to transform the data into proactive, predictive, preventive, and participatory health. As a result of advances in translational informatics, the care of neonates will become more data driven, evidence based, and personalized.
View details for PubMedID 22924023
An evidence-based approach to activating your EMR.
Healthcare informatics : the business magazine for information and communication systems
2011; 28 (12): 47-?
View details for PubMedID 22233021
Evidence-Based Medicine in the EMR Era
2011; 365 (19): 1758-1759
View details for DOI 10.1056/NEJMp1108726
View details for Web of Science ID 000296762800003
View details for PubMedID 22047518
A 15-Year-Old Girl with Dysphagia, Failure to Thrive
2011; 40 (8): 397-400
View details for DOI 10.3928/00904481-20110708-05
View details for Web of Science ID 000305740900005
View details for PubMedID 21815600
Impact of electronic medical record integration of a handoff tool on sign-out in a newborn intensive care unit
2011; 31 (5): 311-317
Objective:To evaluate the impact of integrating a handoff tool into the electronic medical record (EMR) on sign-out accuracy, satisfaction and workflow in a neonatal intensive care unit (NICU).Study Design:Prospective surveys of neonatal care providers in an academic children's hospital 1 month before and 6 months following EMR integration of a standalone Microsoft Access neonatal handoff tool.Result:Providers perceived sign-out information to be somewhat or very accurate at a rate of 78% with the standalone handoff tool and 91% with the EMR-integrated tool (P < 0.01). Before integration of neonatal sign-out into the EMR, 35% of providers were satisfied with the process of updating sign-out information and 71% were satisfied with the printed sign-out document; following EMR integration, 92% of providers were satisfied with the process of updating sign-out information (P < 0.01) and 98% were satisfied with the printed sign-out document (P<0.01). Neonatal care providers reported spending a median of 11 to 15 min/day updating the standalone sign-out and 16 to 20 min/day updating the EMR-integrated sign-out (P = 0.026). The median percentage of total sign-out preparation time dedicated to transcribing information from the EMR was 25 to 49% before and <25% after EMR integration of the handoff tool (P < 0.01).Conclusion:Integration of a NICU-specific handoff tool into an EMR resulted in improvements in perceived sign-out accuracy, provider satisfaction and at least one aspect of workflow.
View details for DOI 10.1038/jp.2010.202
View details for Web of Science ID 000289982300003
View details for PubMedID 21273990
Computerized Physician Order Entry With Decision Support Decreases Blood Transfusions in Children
Timely provision of evidence-based recommendations through computerized physician order entry with clinical decision support may improve use of red blood cell transfusions (RBCTs).We performed a cohort study with historical controls including inpatients admitted between February 1, 2008, and January 31, 2010. A clinical decision-support alert for RBCTs was constructed by using current evidence. RBCT orders resulted in assessment of the patient's medical record with prescriber notification if parameters were not within recommended ranges. Primary end points included the average pretransfusion hemoglobin level and the rate of RBCTs per patient-day.In total, 3293 control discharges and 3492 study discharges were evaluated. The mean (SD) control pretransfusion hemoglobin level in the PICU was 9.83 (2.63) g/dL (95% confidence interval [CI]: 9.65-10.01) compared with the study value of 8.75 (2.05) g/dL (95% CI: 8.59-8.90) (P < .0001). The wards' control value was 7.56 (0.93) g/dL (95% CI: 7.47-7.65), the study value was 7.14 (1.01) g/dL (95% CI: 6.99-7.28) (P < .0001). The control PICU rate of RBCTs per patient-day was 0.20 (0.11) (95% CI: 0.13-0.27), the study rate was 0.14 (0.04) (95% CI: 0.11-0.17) (P = .12). The PICU's control rate was 0.033 (0.01) (95% CI: 0.02-0.04), and the study rate was 0.017 (0.007) (95% CI: 0.01-0.02) (P < .0001). There was no difference in mortality rates across all cohorts.Implementation of clinical decision-support alerts was associated with a decrease in RBCTs, which suggests improved adoption of evidence-based recommendations. This strategy might be widely applied to promote timely adoption of scientific evidence.
View details for DOI 10.1542/peds.2010-3252
View details for Web of Science ID 000290097800002
View details for PubMedID 21502229
Sociotechnical Challenges of Developing an Interoperable Personal Health Record Lessons Learned
2011; 2 (4): 406-419
OBJECTIVES: To analyze sociotechnical issues involved in the process of developing an interoperable commercial Personal Health Record (PHR) in a hospital setting, and to create guidelines for future PHR implementations. METHODS: This qualitative study utilized observational research and semi-structured interviews with 8 members of the hospital team, as gathered over a 28 week period of developing and adapting a vendor-based PHR at Lucile Packard Children's Hospital at Stanford University. A grounded theory approach was utilized to code and analyze over 100 pages of typewritten field notes and interview transcripts. This grounded analysis allowed themes to surface during the data collection process which were subsequently explored in greater detail in the observations and interviews. RESULTS: Four major themes emerged: (1) Multidisciplinary teamwork helped team members identify crucial features of the PHR; (2) Divergent goals for the PHR existed even within the hospital team; (3) Differing organizational conceptions of the end-user between the hospital and software company differentially shaped expectations for the final product; (4) Difficulties with coordination and accountability between the hospital and software company caused major delays and expenses and strained the relationship between hospital and software vendor. CONCLUSIONS: Though commercial interoperable PHRs have great potential to improve healthcare, the process of designing and developing such systems is an inherently sociotechnical process with many complex issues and barriers. This paper offers recommendations based on the lessons learned to guide future development of such PHRs.
View details for DOI 10.4338/ACI-2011-06-RA-0035
View details for Web of Science ID 000208686800002
View details for PubMedID 22003373
Neonatal Informatics: Information Technology to Support Handoffs in Neonatal Care.
2011; 2011 (12)
Communication failures during physician handoffs represent a significant source of preventable adverse events. Computerized sign-out tools linked to hospital electronic medical record systems and customized for neonatal care can facilitate standardization of the handoff process and access to clinical information, thereby improving communication and reducing adverse events. It is important to note, however, that adoption of technological tools alone is not sufficient to remedy flawed communication processes. OBJECTIVES: After completing this article, readers should be able to: Identify key elements of a computerized sign-out tool.Describe how an electronic tool might be customized for neonatal care.Appreciate that technological tools are only one component of the handoff process they are designed to facilitate.
View details for PubMedID 22199463
Neonatal Informatics: Computerized Physician Order Entry.
2011; 12: 393-396
Computerized physician order entry (CPOE) is the feature of electronic medical record (EMR) implementation that arguably offers the greatest quality and patient safety benefits. The gains are potentially greater for critically ill neonates, but the effect of CPOE on quality and safety is dependent upon local implementation decisions. OBJECTIVES: After completing this article, readers should be able to: Define the basic aspects of CPOE and clinical decision support (CDS) systems.Describe the potential benefits of implementing CPOE associated with CDS in a neonatal intensive care unit (NICU).
View details for PubMedID 21804768
Implementing an Interoperable Personal Health Record in Pediatrics: Lessons Learned at an Academic Children's Hospital.
Journal of participatory medicine
2011; 3
This paper describes the development of an innovative health information technology creating a bidirectional link between the electronic medical record (EMR) of an academic children's hospital and a commercially available, interoperable personal health record (PHR). The goal of the PHR project has been to empower pediatric patients and their families to play a more active role in understanding, accessing, maintaining, and sharing their personal health information to ultimately improve health outcomes. The most notable challenges proved more operational and cultural than technological. Our experience demonstrates that an interoperable PHR is technically and culturally achievable at a pediatric academic medical center. Recognizing the complex social, cultural, and organizational contexts of these systems is important for overcoming barriers to a successful implementation.
View details for PubMedID 21853160
Vitamin D-Deficient Rickets in a Child With Cow's Milk Allergy
2010; 25 (4): 394-398
This article describes the case of a 16-month-old Hispanic male toddler with cow's milk allergy living in northern California who was admitted to a children's hospital for weight loss and markedly elevated levels of serum alkaline phosphatase and parathyroid hormone. At a routine outpatient well-child visit, his mother expressed concern about a decrease in his appetite and activity level. A detailed diet history revealed that breast milk was his primary source of nutrition during his first year of life and he had not been given supplemental vitamins. With attempts to introduce cow's milk formula, he had developed a rash and swelling around the mouth. Shortly after his first birthday, his mother weaned him from breast milk and introduced unfortified rice milk as a palatable milk substitute. Upon admission he was pale and lethargic; his laboratory studies were remarkable for elevated serum alkaline phosphatase and parathyroid hormone and low levels of phosphorus, 25-hydroxy-vitamin D, and ferritin. Lower extremity radiographic studies were consistent with rickets. After 5 weeks of therapy with vitamin D(3) and iron, his serum 25-hydroxy-vitamin D level normalized. Within 12 weeks following therapy, the child demonstrated significant clinical improvement, with resolution of growth failure and bone reossification. His activity level had returned to normal. This case emphasizes the importance of adequate vitamin D intake for children with special attention to those who might have nutrition deficiencies attributable to milk allergy.
View details for DOI 10.1177/0884533610374199
View details for Web of Science ID 000283800100011
View details for PubMedID 20702845
Decrease in Hospital-wide Mortality Rate After Implementation of a Commercially Sold Computerized Physician Order Entry System
2010; 126 (1): 14-21
Implementations of computerized physician order entry (CPOE) systems have previously been associated with either an increase or no change in hospital-wide mortality rates of inpatients. Despite widespread enthusiasm for CPOE as a tool to help transform quality and patient safety, no published studies to date have associated CPOE implementation with significant reductions in hospital-wide mortality rates.The objective of this study was to determine the effect on the hospital-wide mortality rate after implementation of CPOE at an academic children's hospital.We performed a cohort study with historical controls at a 303-bed, freestanding, quaternary care academic children's hospital. All nonobstetric inpatients admitted between January 1, 2001, and April 30, 2009, were included. A total of 80,063 patient discharges were evaluated before the intervention (before November 1, 2007), and 17,432 patient discharges were evaluated after the intervention (on or after November 1, 2007). On November 4, 2007, the hospital implemented locally modified functionality within a commercially sold electronic medical record to support CPOE and electronic nursing documentation.After CPOE implementation, the mean monthly adjusted mortality rate decreased by 20% (1.008-0.716 deaths per 100 discharges per month unadjusted [95% confidence interval: 0.8%-40%]; P = .03). With observed versus expected mortality-rate estimates, these data suggest that our CPOE implementation could have resulted in 36 fewer deaths over the 18-month postimplementation time frame.Implementation of a locally modified, commercially sold CPOE system was associated with a statistically significant reduction in the hospital-wide mortality rate at a quaternary care academic children's hospital.
View details for DOI 10.1542/peds.2009-3271
View details for Web of Science ID 000279431000003
View details for PubMedID 20439590
Improved physician work flow after integrating sign-out notes into the electronic medical record.
Joint Commission journal on quality and patient safety / Joint Commission Resources
2010; 36 (2): 72-78
In recent years, electronic sign-out notes have been identified as a means of enhancing the effective transfer of patient care between providers. Such a tool was developed and implemented within the electronic medical record (EMR) system, and its impact on physician work flow was assessed.A printable sign-out report was implemented within the EMR system at a tertiary academic children's hospital. Month 1 post go-live survey data were collected in June and July 2006, and 6-month post go-live survey data were collected in November and December 2006. Use of the sign-out form to document handoff data between go-live and Month 16 (September 2007) was measured using log data from the EMR. Housestaff physicians were asked to report the impact of the tool on their work flow and satisfaction with the sign-out process through a Web-based survey.The sign-out report was steadily adopted following its introduction. Between the first and second surveys, use of EMR-integrated sign-out increased from 37% to 81% of respondents for day-to-night sign-out (chi2 = 12.79, p < .001) and from 14% to 39% for night-to-day sign-out (chi 2 = 5.08, p < .05). With increased use of the report, housestaff reported less time devoted to redundant data entry and increased satisfaction with the sign-out process.EMR-integrated sign-out documents offer the advantages of other electronic network-accessible systems and can also incorporate information already in the medical record in an automated manner. Although the primary motivation for introducing standardized, EMR-integrated sign-out documents is to enhance the safety of patient handoffs, the perception of improved physician work flow is also a benefit of such an intervention.
View details for PubMedID 20180439
Development of a Web-based decision support tool to increase use of neonatal hyperbilirubinemia guidelines.
Joint Commission journal on quality and patient safety / Joint Commission Resources
2009; 35 (5): 256-262
The 2004 American Academy of Pediatrics (AAP) guidelines for management of hyperbilirubinemia in the newborn infant at > or =35 weeks of gestation recommend that clinicians systematically asses the risk of severe hyperbilirubinemia before hospital discharge. Using the guidelines requires access to the printed nomograms, calculation of the infant's age in hours, and manual plotting of total bilirubin results. The combination of a common clinical problem with the existence of guidelines for best practice is an ideal target for clinical informatics tools to help improve compliance. A Web-based clinical decision support tool was developed on the basis of a combination of published data and linear extrapolation to automate the hour-specific risk stratification nomogram and phototherapy nomogram.After BiliTool, the clinical decision support tool that contained the AAP clinical guidelines, was made publicly available, Web-site usage was monitored. An online survey composed of 10 multiple-choice, Likert-scale, and yes-no questions was made available.The number of site visits has increased over time. Of the 469 respondents to the survey, 297 respondents considered themselves tool "users".Rapid uptake and high ratings for clinical utility confirm that Web-based clinical decision support tools are in high demand and may increase use of clinical guidelines. Given the risk of human error with manual age calculation and nomogram plotting, this tool may also decrease the likelihood of medical errors, particularly with integration into the electronic medical record. Concomitant release of Web-based decision support tools with clinical guidelines would optimize the guidelines' adoption and implementation. Also, the integration of BiliTool into the electronic medical record may serve as a model for integrating other Web-based clinical decision support tools.
View details for PubMedID 19480378
Alphanumeric paging in an academic hospital setting
2006; 191 (4): 561-565
To determine whether implementation of an alphanumeric-paging system would improve physician work environment.Surveys were distributed to all general surgery residents, faculty, and nurses before and after implementation of an alphanumeric-paging system. Housestaff also kept a detailed log of paging activity before and after the intervention.User satisfaction with the paging system was measured using a Likert format survey. Interruptions to patient care and pages requiring a call back were tracked using paging logs.Physician perceptions of the capability of text paging before the intervention were high and did not differ significantly postintervention. For nursing staff, postintervention perceptions of the text-paging system were significantly more positive than preintervention, especially with regard to perceived improvements in patient care (54.1% versus 81.6%, P < .05). Residents' paging logs reflected significantly decreased interruptions to patient care after the intervention (28.2% versus 46.9%, P < .05), with less pages requiring a call back (100% versus 73.6%, P < .05).Study participants rated the alphanumeric-paging system highly. Text-paging technology has the potential to reduce interruptions in patient care and improve physician work efficiency and satisfaction.
View details for DOI 10.1016/j.amjsurg.2005.06.037
View details for Web of Science ID 000236508800024
View details for PubMedID 16531156
Perceived increase in mortality after process and policy changes implemented with computerized physician order entry
2006; 117 (4): 1450-1451
View details for DOI 10.1542/peds.2005-3048
View details for Web of Science ID 000236540500088
View details for PubMedID 16585351
Index of suspicion
2004; 25 (10): 364-369
View details for Web of Science ID 000232154200005
View details for PubMedID 15466138
A practical guideline for calculating parenteral nutrition cycles.
Nutrition in clinical practice
2003; 18 (6): 517-520
Both physiologic and psychological reasons for cycling total parenteral nutrition (TPN) have been well established. Despite widespread acceptance of this practice, the only previously published method for calculating TPN cycle rates is inherently flawed.A mathematical formula was derived to facilitate reliable calculation of cyclic TPN flow rates as a function of total volume and cycle time. A publicly accessible website was subsequently developed to expedite rapid determination of TPN cycles.A fail-safe method of calculating TPN cycle flow rates can be expressed as F = V/(4T-10), where F is equal to the basal flow rate (mL/h), T is equal to the desired cycle time (hours), and V is equal to the total volume of TPN (mL) to be delivered in 24 hours. The basal flow rate and twice the basal flow rate are used for the first and last 2 hours of the TPN cycle, and the remainder of the cycle runs at 4 times the basal flow rate. TPN cycles may be easily calculated online using this formula at http://peds.stanford.edu/tpn.html.We have developed a fail-safe method of calculating TPN cycle flow rates that will consistently deliver the desired volume and have made an online implementation of this formula publicly available.
View details for PubMedID 16215087
Isolation of Leclercia adecarboxylata from an infant with acute lymphoblastic leukemia
2001; 32 (11): 1659-1659
View details for Web of Science ID 000168588500027
View details for PubMedID 11340546


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SummitMedia Honolulu currently has an opening for a Vice President of Sales to oversee the sales department for all six SummitMedia Honolulu radio stations. This position is responsible for creating, driving, and achieving revenue goals of the cluster. Duties include but are not limited to developing, strategizing and executing a comprehensive sales plan designed to achieve revenue goals, training and developing a talented sales staff, monitoring sales activities on the stations, and making client calls with the sales staff.
Ideal candidate must have the following:
- A minimum of four years of experience in radio or television sales with a demonstrated ability to develop and drive revenue.
- Prior experience in preparation of marketing proposals.
- Ability to manage individual sellers and train sellers on techniques in successful selling.
- Experience with assisting sellers in finding and developing new local clients
- Monitoring the daily activity of the sales personnel.
- Developing systems to properly manage local accounts and station rates.
- Experience with Non-traditional revenue and Digital sales is required. .
- Maintain a "bank" of potential sales personnel for possible future employment.
- Knowledge of Tapscan, and Scarborough Research is required.If interested in applying for this position please forward a resume to:Attn: Helen Mitchell or email to email@example.com is the policy of SummitMedia LLC to provide equal employment opportunity to all qualified individuals without regard to their race, color, religion, national origin, age, or sex in all personnel actions including recruitment, evaluation, selection, promotion, compensation, training, and termination.
- Discrimination because of race, color, religion, national origin, age, or sex is prohibited. If you believe you have been the victim of discrimination, you may notify the Federal Communications Commission, the Equal Employment Opportunity Commission, or other appropriate agency.
- SummitMedia Birmingham 2700 Corporate Drive Suite 115 Birmingham, AL. 35242
Position: Digital Sales Specialist
SUMMIT MEDIA HAWAII IS SEEKING A DIGITAL SALES SPECIALIST! IF YOU POSSESS THE FOLLOWING SKILLS, WE HAVE THE PERFECT CAREER FOR YOU. OUR DIGITAL SALES SPECIALIST will rEpresent summitmedia hawaii as digital expert for search MARKETING mobile targeting, social media, display advertising, and website deveLopment. THIS INDIVIDUAL WILL Assist the sales team with developing digital strategy recommendations utilizing our digital product suitE, Create sales presentations, ATTEND SALES CALLS AS THE DIGITAL EXPERT FOR SUMMIT MEDIA, and work with the digital execUtion team for campaign manAgement for all digital CAMPAIGNS. TO APPLY, PLEASE send your resume to firstname.lastname@example.com or CALL 275-1031.
Position: Sales Account Manager
Full Time commissioned sales
Excellent benefits package available
Job Description: SummitMedia Hawaii, home to the state's top radio stations is seeking Account Managers. Creative and energetic self-starters must enjoy prospecting and developing new business. Account Managers must be able to quickly grow revenue for company while helping advertising partners grow their business through integrated marketing solutions. Account Managers report directly to their Local Sales Manager.
Experience Preferred: 2+ years Sales & or Marketing experience or 2 years of Broadcast Experience with a proven record of new business development success desired. Experience with digital marketing, SEO/SEM, social and mobile sales a plus. Developing proposals with PowerPoint, Publisher, and Microsoft Word desired. Excel spreadsheet knowledge a plus.
Responsibilities: Prospecting and developing new leads, working with clients to create marketing plans, selling events, digital, social and mobile products. Additional responsibilities include invoicing, collections, renewals and various office paperwork. Training provided.
Direct Resume To: Veronica Yamagata or Fax 275-1196 or e mail
Veronica.Yamagata @summitmediacorp.com
Note: No phone calls – Applicant will be notified for interview

subset: commoncrawl


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UCITS depositary regime clarified by the CSSF
On 11 July 2014, the Commission de Surveillance du Secteur Financier (CSSF) issued a new circular 14/587 applying to undertakings for collective investment in transferable securities (UCITS) depositary banks and to the UCITS themselves regarding their relationship with their depositaries.
The purpose of such circular is to update the depositary regime of Luxembourg UCITS in order to align it with the requirements imposed by Directive 2011/61/EU of the European Parliament and of the Council of 8 June 2011 on alternative investment fund managers in anticipation of the implementation of the UCITS V Directive into Luxembourg law.
The circular provides with the new regulations relating, inter alia, to (i) asset segregation within the depositary through the delegation chain, (ii) initial and ongoing due diligence procedure on all sub-depositaries, (iii) conflicts of interest policy and (iv) adequate booking and monitoring of cash flows. It also describes organisational rules and rules of conduct that a credit institution should comply with to be approved as a UCITS depositary…
Click on the link below to read the rest of the Wildgen briefing.
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Egyptian giants Al Ahly need only a draw in a Cairo showdown with bitter domestic rivals Zamalek on Sunday to advance from Group A to the CAF African Champions League semi-finals, and ASEC Mimosas of Ivory Coast can join them provided they overcome Dynamos of Zimbabwe in Abidjan a day earier.
Leaders Cotonsport Garoua of Cameroon visit Tout Puissant Mazembe of the Democratic Republic of Congo, and second-placed Enyimba of Nigeria host Al-Hilal of Sudan in Group B on Sunday knowing maximum points will take them through.
Decades-long adversaries Ahly and Zamalek share the record for African Champions League titles with five each, but the similarity ends there as the former have been dominant at national and international level for five years.
When the clubs clashed last June in the opening round, Ahly triumphed 2-1 via goals from Angola striker Flavio Amado and Egypt captain and midfielder Ahmed Hassan. A week later it was 2-0 to Ahly in the pre-season Egypt Super Cup, with veteran Hassan, a mid-year signing from Belgian club Anderlecht, again on target.
Zamalek coach Reiner Hollmann is unperturbed by these reverses, telling the club website: "Our chances to advance to the semi-finals are equal to those of our group competitors." But the grim reality facing the German is that if Ahly take even one point from a match likely to draw a 70,000 sell-out crowd and resurgent ASEC triumph, it will be all over for Zamalek.
After losing to Dynamos and drawing with Ahly, ASEC took four points off Zamalek from a draw in Cairo and win in Abidjan to move a point ahead of the Egyptian "White Knights' and two in front of the Zimbabwean 'Glamour Boys'.
Mazembe mauling
Enyimba welcome back leading 2008 African Champions League scorer Stephen Worgu from suspension as they try to recover from a 3-0 mauling at Mazembe two weeks ago that saw them slip to second place a point behind Cotonsport.
While Enyimba also lost at Hilal, ironically to a late goal from Nigerian Ifeanyi Onigbo, they are formidable in their Aba fortress with five qualifying and group matches yielding 17 goals.
Teenager Worgu, who has hit the target 12 times in African combat this year, offers no secret for his success: "I just want to win and win well and that is all I have in mind when I play," he told a Nigerian magazine.
Hilal, favoured to reach the semi-finals after reaching that stage last year, surrendered the advantage of a bright mini-league start by taking a solitary point from a possible six against Cotonsport. The club from the north west Cameroon town of Garoua have been the revelation of the pool phase despite the resignation of French coach Denis Lavagne after a late goal brought a home win over Mazembe three months ago.
However, should a Mazembe team inspired by captain and striker Mputu Mabi match the form that overwhelmed Enyimba, Cotonsport may have to try for a semi-finals place again next weekend when the final fixtures are staged.


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- Filed Under
The Tallahassee City Commission heard a proposed ordinance on Wednesday that would allow development of a hotel at the intersection of East Tennessee and North Monroe streets.
The McKibbon Hotel Group of Gainesville, Ga., plans to build a Hampton Inn adjacent to Aloft Hotel, which it built in 2008. The plan requires approval from the Commission to continue.
When plans for Aloft were originally under review, McKibbon agreed to use the site at the intersection to build condominiums and offices, but since then market conditions changed. ...


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TV Guide recently asked readers to name their favorite television couples. Not surprisingly, Ned (Lee Pace) and Chuck (Anna Friel) made the cut:
Ned and Chuck are a Top TV CoupleMatt Richenthal at . Comments
Matt Richenthal is the Editor in Chief of TV Fanatic. Follow him on Twitter and on Google+.


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User Login
"Working together to develop chilrden's communication skills" Therapy at your child's home, preschool or school. Empowering parents and teaching staff how to continue to develop children's communication skills.
Miranda NSW 2228
JaCS CLaSS provides speech, language and literacy assessment, therapy and resources designed for the young through to the elderly. The service is especially designed to provide training and assistance to the whole family. Effective intervention is dependent on successfully engaging my clients and assisting them to feel motivated by their own successes and progress according to their own individual goals
160 Progress Road, Eltham North VIC 3095


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Florence M. Cook
unknown - September 30, 2013
Florence M. Cook, 86, of Jordan, passed away Monday, Sept. 30, 2013, at home. Born in Waverly, Florence lived in Jordan since1945. She enjoyed knitting, reading, and puzzles as well as bowling and swimming. Florence was a devoted wife of 66 years and a proud mother of two children and she adored her grandchildren.
Surviving are her husband Robert C. Cook, son Ronnie C. (Teri) Cook of Mooresville, NC, daughter Victoria L. (Brian) Woodward of Elbridge, brother William (Monica) Hardy of Jordan, 2 sisters Emma (Robert) Milton of Jordan and Betty McMillan of Fla., 4 grandchildren Adrienne, Justin, Melinda and Joshua, 6 great grandchildren, several nieces and nephews.
Services: 1 p.m. Friday, Oct. 4, at the Bush Funeral Home 120 E. Main St., Elbridge with the Rev. Dana Horrell officiating. Burial will be in Maple Grove Cemetery. Calling hours: 3-7 p.m. Thursday, Oct. 3, at the funeral home. Contributions may be made to the Jordan Ambulance Fund.
Use the form below to express your condolences.


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For now, at least, Sunday's battle between the Fire and New York Red Bulls is the most important match of the weekend in Major League Soccer.
The Fire needs a win to clinch a playoff berth. The Red Bulls, the host team on Sunday, need a win to clinch their first honor -- the MLS Supporters Shield, which goes to the club with the most standings points in the regular season.
By the time the teams take the field, however, the edge could be off for the Red Bulls and by halftime the Fire might not be sweating it out quite so much, either. It's a complicated scenario that will unfold over the weekend, and it's hard to imagine an ending that would be more suspenseful.
Sporting Kansas City, in second place behind the Red Bulls in the Eastern Conference, has 55 points going into Saturday's match at Philadelphia. New York (16-9-8) has 56. If SKC loses its road match, the Red Bulls will be assured the most points in the East. (A win is worth three points and a draw one).
[RELATED: Fire talk about upcoming game against Red Bulls]
If the Portland Timbers tie or lose their last regular season match at Chivas USA on Saturday, the Red Bulls will claim the Supporters Shield with a tie on Sunday. Real Salt Lake, the points leader in the Western Conference, also has 56 but its season is over. Portland has 54 points and will put pressure on the Red Bulls with a win on Saturday night.
On the Fire's side, a playoff berth will be assured if New England doesn't win at Columbus or Houston doesn't win at D.C. United on Saturday. Both those matches start before the Fire and Red Bulls take the field.
Another match that affects the Fire is the Montreal at Toronto match on Saturday. The Fire (14-12-7) could move into third place in the East with a victory if the Impact falters. The standings are super-tight in places three through seven and only five teams will advance to postseason play, which begins next Wednesday with the first of the two Knockout Round matches between teams finishing fourth and fifth in the standings.
The point standings for the bubble teams going into Saturday's matches show Montreal in third place with 49 points and Philadelphia in seventh with 46. In between (with tiebreakers affecting the positions in the standings, are the Fire (49), New England (48) and Houston (48).
[MORE: Fire look to move into third place in New York]
Patrick Nyarko, the Fire's veteran outside midfielder, thinks it's a blessing the playoff battle is going down to the last game.
"I always think back to last year, when we clinched early," said Nyarko. "We took our concentration off a little bit. That didn't help us going into the playoffs."
That's for sure. The Fire hosted the Knockout Round match against Houston and lost 2-1. The Dynamo went on to the MLS Cup final for the second straight year, losing to the Los Angeles Galaxy.
The Fire has a good record against the Red Bulls over the years. They helped New York open Red Bull Arena on March 27, 2010, and lost 1-0 as present Fire midfielder Joel Lindpere scored the lone goal of the match for the host team. Lindpere joined the Fire this season and leads the team with seven assists.
After that first visit to Red Bull Area, however, the Fire has played the Red Bulls tough. They met again in 2010, the teams battling to a scoreless draw. They also played to two draws in the 2011 regular season but the Fire hammered New York 4-0 in the quarterfinals of the Lamar Hunt U.S. Open Cup.
Last season the Fire won two of three matches with the Red Bulls and this season the Fire was a 3-1 winner on April 7 at Toyota Park in their only previous meeting.
[MORE: Fire win boosts team into fourth place]
The Fire will have to cope without veteran midfielder Jeff Larentowicz on Sunday. He'll sit out a one-game suspension for the red card he drew in the 1-0 victory over Toronto FC in last Saturday's regular season home finale. Though Larentowicz wore the armband most of the season, official captain Logan Pause could be on the field in his place on Sunday. Alex, the up-and-coming Brazilian midfielder, is also an option as Larentowicz' replacement
Also on the line is the MLS Golden Boot. The Fire's Mike Magee is tied for the lead with Montreal's Marco Di Vaio. Both have 20 goals – the 11th and 12th players to score that many in an MLS regular season – and Magee has 14 of his with the Fire since coming to the club in an early season trade with Los Angeles.
Magee is also in the hunt for the Most Valuable Player award, though the Fire may need to make the playoffs for him to get enough voting support.
"I know what's really at stake, and it's not the MVP award or the Golden Boot or any other award,'' said Magee. "It's about getting into the playoffs and knowing that anything can happen from there."


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Star Trek Online Discussion Thread (now free to play!)
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July 16 2012, 11:49 PM
Location: Out there. Thatta way.
Re: Star Trek Online Discussion Thread (now free to play!)
intrinsical wrote:
And every time you use a boff ability, you're really using a small amount of Cryptic's server. I'm guessing they've calculated the average number of time boff abilities is used over a period of time and figured out how much it costs to run STO servers and pay developers for that period of time. And that gives them a baseline cost of how much ships need to cost in order to run a profitable service.
Nah. That's not how they price things like this. Cost is minuscule when you're dealing with intangibles like this. Pennies per ship per year. The price floor is set by the man hours it takes to develop new content plus an acceptable margin for shareholders. Mind you, that's the floor, what the price might be during sales.
When they're setting the standard price for new items they base it on what has and hasn't worked in the past. Basically, price it at what the market will pay. They pick a balance between price per unit and number of units sold (x*y=z, where z is maximized) and that's what they price things at.
An egotist is someone more interested in himself than me.
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Cathedral Boys Basketball - Page 3
Boys Basketball Results; Cathedral Routs Milaca
Boys Basketball Results; Rocori Downs Alexandria
Cathedral Boys Basketball Falls To Zimmerman
The Cathedral Boys Basketball team lost 92-70 to Zimmerman in the section 5AA Semifinals at St. Michael-Albertville High School Tuesday night. The Crusaders trailed 56-36 at halftime and couldn't catch up in the 2nd half. Bjorn Bjorklund led Cathedral with 23 points and 8 rebounds and Joe Burt added 16 points.


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Droid 2 R2-D2 edition -- a poster next to that demo unit at the Star Wars-themed Celebration V convention in Orlando says it's due to arrive on September 30. Unfortunately there's no word on how much more this thing will cost over the regular Droid 2, but hey -- Artoo's worth it, right? Check a couple more high-res shots at the source link.
*Verizon has acquired AOL, Engadget's parent company. However, Engadget maintains full editorial control, and Verizon will have to pry it from our cold, dead hands.
Buy from $69
- Key specs
- Prices
- Discussions
- Type Smartphone
- Operating system Android (Froyo [2.2])
- Screen size 3.7 inches
- Internal memory 8 GB
- Carriers (US) Verizon / Alltel
- Dimensions 4.58 x 2.38 x 0.54 in
- Weight 5.96 oz
- Announced 2010-08-13


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Voices from the Field: The Social Construction of Alcohol Problems in Inner-City Communities
Herd, Denise, Contemporary Drug Problems
This study examines the social construction of alcohol problems by activists involved in alcohol policy campaigns in inner-city neighborhoods in the 1990s. Nearly 200 informants were interviewed and asked to describe why they thought local neighborhoods mobilized around alcohol policy issues. In contrast with other social movements that have emphasized individual alcohol problem or addiction experiences, informants in this study focused on the role of alcohol outlets and sales and marketing in contributing to various forms of social disorder, such as crime, violence, illicit drug use, public intoxication, and nuisances that were engulfing their neighborhoods. These themes were interpreted in light of the social conditions faced by inner-city residents in the 1980s and 1990s, including the crack cocaine epidemic, the spectacular rise in youth violence, aggressive new alcoholic beverage marketing campaigns, and the increasing rates of poverty in dilapidated urban centers.
KEY WORDS: Alcohol policy, social movements, drugs, racial minorities, crime, urban problems.
The social construction of problems has been recognized as a critical issue in social movement theory. Within the field of alcohol studies, the social constructionist perspective has been used to analyze the history of the temperance and prohibition movements (Levine, 1978); the rise of the alcoholism as a disease movement in the post-prohibition era (Room, 1983); and the crusade against drinking and driving in the 1980s in the United States (Reinarman, 1988). These studies analyzed the shifts in social meanings attributed to alcohol beverage use and to problems within the changing landscapes of social, economic, and political power relationships in American society.
The present study examined the social construction of alcohol problems within the social movement focused on changing alcohol policies in American inner-city neighborhoods in the 1980s and 1990s. This movement, peopled by ethnic minority residents and human service professionals working in social service agencies, law enforcement, and education, sought to change local and regional policies and legislation regarding alcohol sales and marketing in many cities across the United States. Since the 1970s, and most dramatically in the late 1980s and 1990s, these activists voiced open opposition to alcohol outlets, billboards, and alcohol advertising practices in their communities. They developed local ordinances to limit and regulate alcohol outlets, mobilized networks to eliminate alcohol billboard advertising, and launched campaigns to protest efforts by alcohol and tobacco companies to market products targeted at African Americans in the inner city, especially youth (Harney, 1992; Jernigan & Wright, 1994; Ronningen, 1993).
Collectively, these efforts can be considered a social movement, as defined by Snow, Soule, and Kriesi (2007): "collectivities acting with some degree of organization and continuity outside of institutional or organizational channels for the purpose of challenging or defending extant authority" (p. 11). Although falling within this definition, grassroots alcohol-related policy campaigns have been overlooked for the most part by the sizable body of literature focused primarily on such large-scale and well-known initiatives as the labor movement, civil rights movement, women's movement, and environmentalist movement, among others (Fantasia & Stepan-Norris, 2007; Ferree & Mueller, 2007; Rootes, 2007). One of the central questions for any social movement is how social problems are constructed. As noted by Klandermans (1992), social movement theory and the social constructionist perspective both acknowledge that objective social conditions do not necessarily give rise to perceived social problems or social movements.
The idea that social problems are not objective and identifiable conditions but the outcome of processes of collective definition of the situation is not new. …


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R.T. Vanderbilt has introduced Veegum Pure magnesium aluminum silicate, a stabilizing agent specially processed for natural/organic skin care products. Veegum Pure conforms to USP/NF monograph for magnesium aluminum silicate- type IA and Food Chemical Codex monograph for Bentonite.
More info: (203) 853-1400; Website: www.rtvanderbilt.com.
R.T. Vanderbilt Introduces Veegum Pure
Published December 9, 2005
Related Searches: natural • care • Skin Care • Care Products •
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It would be useless to try it, unless you have a large facility with process control computers. You can surely look it up yourself though if you are that interested. It is under the authors and assigned to Kodak.
Since I know both of them personally and worked on the project, I don't need to keep a copy handy here. Sorry.


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Yes, Kim Kardashian's Paper Cover Photo Broke the Internet
It sounds crazy, we know: Kim Kardashian appears in a photo that is sure to generate a ton of publicity.
It sounds crazy, we know: Kim Kardashian appears in a photo that is sure to generate a ton of publicity.
A Domino's Pizza manager in Saginaw was clearly having a bad day, so when an unhappy customer tried to give him some "constructive criticism" it really didn't go her way.
Now, even the most destitute bastard in Flint can be a homeowner. A recent report from The Detroit Free Press indicates there is a house currently on the market that can be purchased for under $200.
According to the just-released 2013 violent crime statistics from the Federal Bureau of Investigation, Flint is much safer than it was in 2012.
The third year of the Michigan Food, Beer and Wine Fest is going to be the best one yet and happens this Saturday (November 8th) at the new Flint Farmer's Market!
We had no idea that seeing Los Santos through the eyes of Trevor would be so beautiful.
One Michigan school official believes every school has drugs in it, which is the reason he launched a campaign to unleash a pack of drug-sniffing dogs on all the schools in his district...
Voters in Genesee County approved three tax increases on the ballot according to MLive, An animal shelter tax of 0.20 mils for seven years...
Something went horribly wrong this afternoon at a Lapeer manufacturing plant.
Flint Police are about to start "slut shaming" the whole city by posting the names and faces of suspected prostitutes and johns on their Facebook page.
Shane works at Walmart's deli and thinks "outside of the box." Unfortunately, his brilliance is not appreciated by management, as evidenced by this collection of disciplinary notes documenting Shane's hilarious antics.


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Redundancy pay
There is a lot of confusion with regards to domestic employees and redundancy. Many people assume that because of the unique circumstances that exist between a domestic employee and their employer, they don't qualify for redundancy pay. But providing they meet the requirements they are entitled to redundancy pay just like any other employee.
To qualify the employee must be 18 or over and have at least two years continuous employment. This means that they must have been working for the same household, without any breaks, apart from maternity, paternity, sickness and unpaid leave, for at least two years. They must also be working as an employee under an employment contract and have a PAYE scheme set up. This does not mean that they need to have a written contract, as some employers unfortunately don't provide this. They are still considered an employee working under a contract even if there is nothing in writing.
If an employer's circumstances change and they no longer have a full-time job to offer their employee and they want to employ someone on a part-time basis, the employer is required to first offer the "new" position to the existing employee. If they choose not to continue working for the employer under the new conditions they are still entitled to redundancy pay, unless they are on a fixed term contract.
The employee will also qualify for redundancy pay if their employer moves to a different part of the country, providing there is no relocation clause in the contract.
For current redundancy pay rates, please refer to the rates and thresholds page.
As long as the employee is on PAYE, they are legally entitled to these amounts; however, the employer is free to pay more than the statutory minimum at their discretion. The employer cannot claim any part of these costs back from the state. The employee does not have to pay tax on redundancy payments up to £30,000.
Please contact Stafftax if you wish to clarify any of the above points.
information for domestic workers
Always insist on a gross wage with your employer
Why are net-wage agreements still so common in domestic employment, especially when you bear in mind the financial implications at stake.Read more ...


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the land of thug nastyness @awesumtaters
207 Images
wow so i just realized how boring my description was! heres a more in depth one: well i love anything old or vintage ( hence the main theme of my blog) yet i also like contemporary things, like spongebob XD anyways im a big movie and music buff (especially 60s and 70s) . anyways follow me cuz i update my blog at least every day when i can :P - the land of thug nastyness (@awesumtaters)


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The Prince Arthur
Prince Arthur serves a range of traditional ales and foods.
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Venue Details & Map
The Prince Arthur
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95 Forest RoadLondonE8 3BH
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- +44 (0)20 7249 9996
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- Hackney Downs, National Railway
Book a taxi on +44 (0)844 556 0706 or with London's biggest car service app
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Jeffrey, I did consider this kind of thing. I haven't tried it before so I wonder what the reproduction quality would be like to photograph prints, in terms of the resolution, contrast, dynamic range and so on. Might have to give it a go.
Alternatively I could probably make 4 near-identical 35mm negatives at the time the picture is taken, although I'd rather they were actually identical. There's a possibility of shooting the picture on transparency which can then be easily copied onto B&W negatives multiple times.
I'm certain it would be cheaper and easier to get the prints made at a lab or even (shock, horror) digitally - but I'm adamant I want to handle the creation of these pictures myself by hand.


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Published on: April 28, 2008
Supermodel Angie Everhart was busted for DUI.
THE LAPD pulled over the intoxicated beauty near the corner of Alexandria and Wilshire.
Everhart was held on a $15,000 bond before being released. The Ange is due back in docket mid May.
Everhart joins a looooooooooong list of celebs that don't know when they've had enough and still get behind the wheel.
Don't they have designated drivers in Drunk Town . . .uh . . . Los Angeles?


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Joe the Art of CoffeeMay 12Coffee Shop • New York, United States
The cold-brewed iced coffee is amazing. Naturally sweet, no sugar needed.
Hi, I'm a nephrologist (that's a kidney and blood pressure specialist), general doctor, and health tech advisor in New York City.
The cold-brewed iced coffee is amazing. Naturally sweet, no sugar needed.
Consistently great. Try the vesper martini, the octopus appetizer, the brie special appetizer, and the rabbit cavatelli.
Good place for a quick beard trim.
Great place for a head shave.
Nephrologist (kidney doctor and hypertension / blood pressure specialist).
Joe's the Art of Coffee is three blocks south (75th an Lex) and is far better. Consider going there instead.
Avoid the Starbucks three blocks north and go here instead.
The coffee beans are fresher, better tasting, and way cheaper than Starbucks.