Letters

In Reply It was good to read the comments of Symvoulakis and colleagues about our recent article on how decisions are made.1 To inform and involve patients in medical decisions is a goal that is valued to varying degrees around the world. It also poses major challenges for health care clinicians around the world, perhaps most acutely in primary care. The writers provide a good list of the problems: the wide variety of medical problems seen in primary care, lack of skills or practice in doing shared decision making, and physicians’ concerns that patients will not do something that they think is medically valuable. It will take some adjusting for physicians to feel comfortable when patients do not make the decisions they would recommend. However, as the writers state: “…striving toward a well-informed and actively involved patient…should become a priority for any health care reform to succeed over time.” We could not agree more.

support algorithms to understand which combination of vital signs and other clinical markers can help identify the patients at risk of clinical deterioration and in need of additional intervention. Furthermore, automating vital sign collection could achieve cost savings by decreasing manual labor, as mentioned by Yoder and colleagues.1 There are already Food and Drug Administration– approved, patient-worn devices that can automatically monitor electrocardiogram, heart rate, blood pressure, oxygen saturation, respiratory rate, temperature, and other variables. This is not science fiction dreaming about the future but an opportunity we have to improve patient care now if we design, select, and implement technology in smart ways. Wen Dombrowski, MD, MBA Author Affiliation: Connected Health, VNA Health Group, Red Bank, New Jersey.

Floyd J. Fowler Jr, PhD Bethany S. Gerstein, BA Michael J. Barry, MD

Corresponding Author: Wen Dombrowski, MD, MBA, VNA Health Group, 176 Riverside Ave, Red Bank, NJ 07701 ([email protected]). Conflict of Interest Disclosures: None reported.

Author Affiliations: Informed Medical Decisions Foundation, Boston, Massachusetts (Fowler, Gerstein, Barry); Center for Survey Research, University of Massachusetts, Boston (Fowler).

1. Yoder JC, Yuen TC, Churpek MM, Arora VM, Edelson DP. A prospective study of nighttime vital sign monitoring frequency and risk of clinical deterioration. JAMA Intern Med. 2013;173(16):1554-1555.

Corresponding Author: Floyd J. Fowler Jr, PhD, Center for Survey Research, University of Massachusetts, Boston, 100 Morrissey Blvd, Boston, MA 02125 ([email protected]).

2. Inouye SK. No rest for the weary…or the sick. JAMA Intern Med. 2013;173(16):1555-1556.

Conflict of Interest Disclosures: All authors are employed by the Informed Medical Decisions Foundation. Dr Barry reported receiving a salary as president of the Informed Medical Decisions Foundation, a nonprofit private foundation. Funding/Support: Funding for data collection and manuscript preparation for the research reported in our study1 was provided by the Informed Medical Decisions Foundation. Role of the Sponsor: The Informed Medical Decisions Foundation is a nonprofit organization that supports research and creates decision support materials for patients. Health Dialog, a for-profit company, uses materials created by the foundation as part of the support services it provides to patients through health plans, employers, and providers, and it pays royalties to the foundation for the use of those materials. 1. Fowler FJ Jr, Gerstein BS, Barry MJ. How patient centered are medical decisions? results of a national survey. JAMA Intern Med. 2013;173(13):1215-1221.

Acutely Ill Patients Will Likely Benefit From More Monitoring, Not Less To the Editor Applause to Yoder et al1 and Inouye et al2 for drawing attention to the important but infrequently discussed problems of waking up hospitalized patients while they are trying to rest. The article by Yoder et al1 suggests checking vital signs less frequently for low-risk patients. However, US patients who are hospitalized nowadays are admitted for increasingly higheracuity and complex care, as health care clinicians engage in efforts to prevent hospital admissions and pursue outpatient treatment when feasible. In light of these trends toward hospitalizing high-acuity patients and the increasing availability of monitoring technology,3,4 further research should focus on (1) less intrusive patient monitoring such as portable, patient-worn sensors that continuously collect vital sign data in hospital and home telehealth settings, and (2) data analytics and decision jamainternalmedicine.com

3. Yilmaz T, Foster R, Hao Y. Detecting vital signs with wearable wireless sensors. Sensors (Basel). 2010;10(12):10837-10862. 4. Welch J, Moon J, McCombie S. Early detection of the deteriorating patient: the case for a multi-parameter patient-worn monitor. Biomed Instrum Technol. 2012;(suppl):57-64.

In Reply We appreciate Dr Dombrowski's thoughtful reply to our article1 and agree on all accounts to the excellent points she has raised regarding the important balance between patient rest and adequate monitoring. The escalating level of acuity in hospitalized patients certainly does necessitate more vigilant vital sign collection, but this can be accomplished without foregoing patient sleep. We are equally enthusiastic about the many newly developed and developing technologies that support continuous vital sign monitoring. Not only are patient-worn devices currently commercially available, but it is now even possible to continuously monitor vital signs, such as heart rate and respiratory rate, without coming in contact with the patient, using a sensor placed under the patient’s mattress.2 These devices are poised to revolutionize the way we care for patients on the wards, obviating the need for reflexive manual vital sign collection. However, their impact on patient sleep remains to be seen. An increasing stream of vital sign data will likely result in more frequent alarms. To prevent more noise in the already deafening hospital, careful alarm delivery via ward redesign and electronic health record or paging alerts should be considered.3 Since each alarm will presumably prompt a manual verification, low-risk patients may end up being woken even more frequently than the status quo if the triggering thresholds are not sufficiently specific. Given concerns over increasing alarm frequency, the Joint Commission has recently called on hosJAMA Internal Medicine March 2014 Volume 174, Number 3

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Letters

pitals to reduce alarm fatigue by identifying situations when alarms are not needed.4 While our study1 elected to use the modified early warning score (MEWS) to demonstrate the inflexibility of our current antiquated vital sign practice, the MEWS is a fairly crude tool, having been developed using expert consensus and being limited in input to just vital signs. More accurate risk prediction algorithms exist and are in development.5 The most accurate among them include additional variables such as laboratory data and demographics. The combination of such an algorithm with better monitoring could further improve detection of clinical deterioration and decrease false alarms. In any case, the century-old standing vital sign check every 4 hours is rightfully fading. In its place comes datadriven, patient-centered, real-time monitoring, which could conceivably result in hospitals that are quiet, restful, and safe. Jordan C. Yoder, MD Vineet M. Arora, MD, MAPP Dana P. Edelson, MD, MS Author Affiliations: Pritzker School of Medicine, University of Chicago, Chicago, Illinois (Yoder); Department of Medicine, University of Chicago, Chicago, Illinois (Arora, Edelson). Corresponding Author: Dana P. Edelson, MD, MS, Section of Hospital Medicine, University of Chicago Medical Center, 5841 S Maryland Ave, Mail Code 5000, Chicago, IL 60637 ([email protected]). Conflict of Interest Disclosures: Dr Arora is supported by the National Institutes of Health/National Institute on Aging (1K23AG033763) and the American Sleep Medicine Foundation. Dr Edelson is supported by a career development award from the National Heart, Lung, and Blood Institute (K23 HL097157-01) and has received research support from Philips Healthcare (Andover, Massachusetts) and Laerdal Medical (Wappingers Falls, New York), and has ownership interest in Quant HC (Chicago, Illinois), which is developing products for risk stratification of hospitalized patients. No other disclosures are reported. 1. Yoder JC, Yuen TC, Churpek MM, Arora VM, Edelson DP. A prospective study of nighttime vital sign monitoring frequency and risk of clinical deterioration. JAMA Intern Med. 2013;173(16):1554-1555. 2. Zimlichman E, Szyper-Kravitz M, Shinar Z, et al. Early recognition of acutely deteriorating patients in non-intensive care units: assessment of an innovative monitoring technology. J Hosp Med. 2012;7(8):628-633.. 3. Yoder JC, Staisiunas PG, Meltzer DO, Knutson KL, Arora VM. Noise and sleep among adult medical inpatients: far from a quiet night. Arch Intern Med. 2012;172(1):68-70. 4. The Joint Commission. Medical device alarm safety in hospitals. Sentinel Event Alert. April 2013; Issue 50. 5. Churpek MM, Yuen TC, Edelson DP. Risk stratification of hospitalized patients on the wards. Chest. 2013;143(6):1758-1765.

Privacy Protection During Internet Search for Health-Related Information To the Editor In a recent Research Letter published in this journal, Huesch1 addresses the important issue of protecting the privacy of individuals who search for health-related information on the Internet. Among the 20 health-related websites he examined for the presence of “third-party tracking elements” and leakage of search terms to third-party tracking entities, 4 are National Institutes of Health (NIH) websites (National Cancer Institute, National Library of Medicine’s PubMed and MedlinePlus, and the main NIH site). Huesch appears cog476

nizant that these 4 websites are federal government websites, but his letter does not clearly or accurately represent how and why government agencies use tracking elements on their websites and the restrictions placed on federal agencies with respect to data collection and sharing. A tracking element is defined in the letter by Huesch1(p1838) as “a long-acting cookie, [Web] beacon, conversion pixel, social media tracking plug-in, or other script that reports to a third party about [a] user’s behavior at current or subsequent sites.” The 4 NIH websites use such tracking elements in conjunction with web analytic tools and customization technologies. These tools and technologies are deployed to determine the numbers of visitors and how visitors navigate the sites and to support website satisfaction surveys. The goal is to improve the organization, navigation, content coverage, and performance of the websites, thereby optimizing the user experience with the sites. However, the collected data are not shared with thirdparty entities, and no personally identifiable information is collected unless a visitor explicitly decides to provide it, eg, through completion of a user input form. Moreover, visitors to these websites have the ability to disable cookies or opt out of surveys if they choose. Guidance to federal agencies regarding the use of web analytic tools and customization technologies is detailed in the Office of Management and Budget’s Memo M-10-22.2 Additional information about the collection and analysis of website use and performance data by federal government agencies can be found at the HowTo.gov website.3 Curiously, Huesch1 did not detect tracking elements on 1 of the 4 NIH websites he examined, ie, the main NIH site. When the tools described in his letter were used to re-examine all 4 sites, as expected, tracking elements were detected on every site. The health-related information disseminated by NIH institutes and centers is widely viewed as accurate and trustworthy. Visitors accessing this information via NIH websites should have every confidence that their privacy and security are protected. John T. Burklow Lenora Johnson, PhD Betsy Humphreys, MLS Author Affiliations: Office of Communications and Public Liaison, National Institutes of Health, Bethesda, Maryland (Burklow); Office of Communications and Education, National Cancer Institute, National Institutes of Health, Bethesda, Maryland (Johnson); National Library of Medicine, National Institutes of Health, Bethesda, Maryland (Humphreys). Corresponding Author: John T. Burklow, Office of Communications and Public Liaison, National Institutes of Health, 1 Center Dr, MSC 0188, Building 1, Room 344, Bethesda, MD 20892-0188 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Huesch MD. Privacy threats when seeking online health information. JAMA Intern Med. 2013;173(19):1838-1839. 2. Office of Management and Budget. Memo M-10-22: Guidance for online use of Web measurement and customization technologies. June 25, 2010. http://www.whitehouse.gov//sites/default/files/omb/assets/memoranda_2010 /m10-22.pdf. Accessed July 16, 2013. 3. General Service Administration Office of Citizen Services and Innovative Technologies and Federal Web Managers Council. Digital metrics for federal agencies. HowTo.gov website. http://www.howto.gov/web-content /digital-metrics. Accessed July 16, 2013.

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