Health Services Research Commons^™

Towards Digital Health Transformation: The Urgency Of Electronic Student Health Reports (Case Study In Sd Negeri Cipedak 03, South Jakarta And Puskesmas Jagakarsa), Retnowati Retnowati, Kemal N. Siregar, Dion Zein Nurizin, Arief Azhari Ilyas

Jurnal Biostatistik, Kependudukan, dan Informatika Kesehatan

The community health center (Puskesmas) routinely collects student health examination data in health report books, causing storage, monitoring, and analysis difficulties. This has led to suboptimal health interventions involving parents, schools, and Puskesmas. This research analyzes user needs in developing an electronic-based student health report. This qualitative descriptive study employs the Framework for the Application of System Thinking (FAST) approach. The research was conducted at the Puskesmas Jagakarsa and SD Negeri Cipedak 03, South Jakarta. The study findings indicate utilizing student health report books is not optimal. Based on the needs analysis, there is a necessity to develop an electronic-based …

Pemodelan Statistik Hubungan Pemenuhan Standar Pelayanan Kesehatan Ibu Dengan Penggunaan Metode Kb Pascapersalinan Di Nusa Tenggara Timur, Sulawesi Barat, Maluku, Nurrachda Hanafi, Martya Rahmaniati, Kemal N. Siregar, Lilik Aryani Falupi

Jurnal Biostatistik, Kependudukan, dan Informatika Kesehatan

Penelitian ini membahas pemenuhan standar pelayanan Kesehatan ibu terhadap penggunaan metode KB Pascapersalinan dengan tujuan mengetahui hubungan antara pemenuhan standar pelayanan Kesehatan ibu terhadap penggunaan metode KB pascapersalinan di NTT, Sulawesi Barat, Maluku. Desain studi cross-sectional dengan analisis multivariabel regresi logistik menggunakan data sekunder SDKI 2017. Jumlah sampel yang digunakan sebesar 404 sampel dengan rincian NTT (151), Sulawesi Barat (115), Maluku (138) pada WUS yang pernah melahirkan anak hidup dalam periode satu tahun terakhir dan menggunakan metode KB pascapersalinan periode 42 hari setelah melahirkan. Proporsi penggunaan metode KB pascapersalinan di NTT 32,5%, Sulawesi Barat 33% dan Maluku 39,9%. Hasil penelitian …

Analisis Spasial Autokorelasi Tuberkulosis Di Pulau Jawa Tahun 2021, Nayaka Nayottama Pamadi, Kemal N. Siregar, Martya Rahmaniati, Atmiroseva Atmiroseva

Jurnal Biostatistik, Kependudukan, dan Informatika Kesehatan

Tuberkulosis (TB) adalah salah satu penyakit menular yang masih menjadi masalah kesehatan masyarakat di Indonesia. Terlebih, adanya pandemi COVID-19 berimbas kepada berkurangnya progress dan penanganan TB di tahun 2021, maka dari itu dilakukan penelitian untuk mengetahui situasi TB dan melihat hubungan spasial pada kasus TB dengan faktor-faktor risikonya di salah satu wilayah dengan jumlah kasus tertinggi di Indonesia; Pulau Jawa, di tingkat kabupaten/kota. Faktor risiko dibagi menjadi dua kelompok, yaitu faktor geografis seperti rata-rata ketinggian, suhu tahunan, dan kelembaban tahunan; serta faktor sosiodemografi yang mencakup kepadatan penduduk/densitas, jumlah fasilitas kesehatan, dan rata-rata usia diagnosis. Hasil penelitian menunjukkan adanya pola mengelompok …

Hubungan Akses Layanan Kesehatan Dengan Penggunaan Metode Kontrasepsi Jangka Panjang Di Indonesia: Analisis Data Skap Kkbpk 2019, Vallery Violila, Tris Eryando, Kemal N. Siregar, Lilik Aryani Falupi

Jurnal Biostatistik, Kependudukan, dan Informatika Kesehatan

Program KB di Indonesia khususnya penggunaan MKJP menjadi upaya pemerintah dalam mengendalikan penduduk, khususnya pada kelompok berisiko. Namun, penggunaan mix-method MKJP di Indonesia relatif masih rendah, yaitu 24,6% dibandingkan negara ASEAN lainnya. Wanita menikah di Indonesia masih mengalami masalah dalam mengakses layanan kesehatan seperti masih tingginya angka unmet-need serta rendahnya presentase wanita terpapar informasi dari penyuluh lapangan KB dan informed choice KB. Penelitian ini bertujuan untuk mengidentifikasi indikator akses layanan kesehatan dan mengetahui hubungan akses layanan kesehatan dengan penggunaan MKJP. Penelitian ini menggunakan data SKAP KKBPK 2019 dengan desain penelitian cross-sectional. Analisis univariat dilakukan untuk mengidentifikasi indikator akses layanan …

Is There Room For Individual Patient-Specified Preferences In The Patient-Reported Outcome Measurement Revolution?, Leif I. Solberg, Jeanette Y. Ziegenfuss, Rachael L. Rivard, Christine K. Norton, Robin R. Whitebird, Glyn Elwyn, Mark Swiontkowski

Journal of Patient-Centered Research and Reviews

Purpose: The study aim was to test the feasibility of collecting qualitative patient-preferred outcomes or goals and the degree of their attainment as an addition to a standardized process for collecting quantitative composite patient-reported outcome measures (PROMs) from patients undergoing knee joint replacement..

Methods: Patients of a large Midwestern medical group scheduled to have total replacement of their knee joint have been asked to complete a PROMs survey preoperatively and at 3 and 12 months after surgery since 2014. In March 2020, an open-ended question about their most important preferred outcome was added to the existing questionnaire. The responses for …

Patients’ Experience Of Specialty Care Coordination: Survey Development And Validation, Varsha G. Vimalananda, Mark Meterko, Kailyn E. Sitter, Shirley Qian, Jolie B. Wormwood, B. Graeme Fincke

Journal of Patient-Centered Research and Reviews

Purpose: Specialty care coordination relies on information flowing bidirectionally between all three participants in the “specialty care triad” — patients, primary care providers (PCPs), and specialists. Measures of coordination should strive to account for the perspectives of each. As we previously developed two surveys to measure coordination of specialty care as experienced by PCPs and specialists, this study aimed to develop and evaluate the psychometric properties of a related survey of specialty care coordination as experienced by the patient, thereby completing the suite of surveys among the triad.

Methods: We developed a draft survey based on literature review, patient interviews, …

A Helping Hand Out Of The River: Refugee Perspectives For Provider Engagement, Brian L. Isakson, Elizabeth R. Stein, Alexandra Olson, Destiny Waggoner, Jill Holtz, Sara Ali, Suha Amer, Martin Ndayisenga

Journal of Patient-Centered Research and Reviews

Purpose: A growing number of refugee groups are seeking care within the U.S. health care system for medical, psychological, and social needs. Research is limited in understanding refugee-specific conceptualizations of helping relationships and provider characteristics that improve interactions in health systems. This study aimed to identify provider characteristics that facilitate engagement and helpfulness in a refugee-specific population from refugee participant voices to inform future practices of health care clinics.

Methods: Semi-structured interviews with refugee participants were conducted to assess 1) experiences moving on from difficult experiences, 2) engagement with the health system, and 3) provider characteristics that facilitated engagement and …

Homebound Older Adult, Caregiver, And Provider Perspectives On The Benefits Of Home-Based Primary Care: A Narrative Review, Nila N. Sabetfakhri

Journal of Patient-Centered Research and Reviews

Home-based primary care (HBPC) is a clinical practice that is being increasingly utilized for the homebound older adult population. As the age demographics in the United States shift over time, these programs will need to be expanded to accommodate the growing aging population. This narrative review aims to compile studies on the benefits of HBPC from the perspective of homebound older adult patients, caregivers, and the health care providers who practice HBPC. Studies were identified through PubMed, Web of Science, and Google Scholar, and a total of 10 papers were included in this review. Identified benefits of HBPC for homebound …

A Clear, Succinct Research Question Portends The Rest Of The Story, Jessica J. F. Kram, Lisa Sullivan Vedder, Brenda Fay, Deborah Simpson

Journal of Patient-Centered Research and Reviews

The goal of any research manuscript is to convey the story of a systematic answer to an important question in the field. A clear, succinct research or study question is what provides the storyline that connects all the sections of a manuscript. One of the most common strategies to developing a meaningful research question is the FINER approach, which encompasses five standards to determine the quality of a question: feasible, interesting, novel, ethical, and relevant. Using the FINER approach can provide the guidepost for all design and reporting decisions. This editorial recommends creating a study protocol aimed at answering your …

Pulmonary Specialist-Supported Health Coaching Delivered By Lay Personnel Improves Receipt Of Quality Care For Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial, Rachel Willard-Grace, Danielle Hessler, Beatrice Huang, Denise Devore, Chris Chirinos, Jessica Wolf, Devon Low, Chris Garvey, Doranne Donesky, Stephanie Tsao, David H. Thom, George Su

Journal of Patient-Centered Research and Reviews

Purpose: Half of people living with chronic obstructive pulmonary disease (COPD) do not receive high-quality, evidenced-based care as described in international guidelines. We conducted secondary data analysis of a previously published study to assess the ability of a model of lay health coaching to improve provision of guideline-based care in a primary care setting.

Methods: As part of a randomized controlled trial, we recruited English- and Spanish-speaking patients with moderate to severe COPD from primary care clinics serving a low-income, predominantly African American population. Participants were randomized to receive usual care or 9 months of health coaching from primary care …

The Impact Of Telehealth In Urgent Care Settings, Annie Dong

Applied Research Projects

Telehealth is an emerging modality of patient care and has since expanded to urgent care facilities. Urgent care facilities have been around for decades; however, along with telehealth, it has only grown in popularity in recent years due to the COVID-19 pandemic. However, the implementation and usage of telehealth in urgent care facilities is dependent on the provider being able to use it. This study aimed at looking at the perspective of the provider on the implementation and usage of telehealth in the urgent care setting.

Reducing Prescribing Of Antibiotics For Acute Respiratory Infections Using A Frontline Nurse-Led Ehr-Integrated Clinical Decision Support Tool: Protocol For A Stepped Wedge Randomized Control Trial, Elizabeth R Stevens, Ruth Agbakoba, Devin M Mann, Rachel Hess, Safiya I Richardson, Thomas Mcginn, Paul D Smith, Wendy Halm, Marlon P Mundt, Katherine L Dauber-Decker, Simon A Jones, Dawn M Feldthouse, Eun Ji Kim, David A Feldstein

Faculty, Staff and Students Publications

Background: Overprescribing of antibiotics for acute respiratory infections (ARIs) remains a major issue in outpatient settings. Use of clinical prediction rules (CPRs) can reduce inappropriate antibiotic prescribing but they remain underutilized by physicians and advanced practice providers. A registered nurse (RN)-led model of an electronic health record-integrated CPR (iCPR) for low-acuity ARIs may be an effective alternative to address the barriers to a physician-driven model.

Methods: Following qualitative usability testing, we will conduct a stepped-wedge practice-level cluster randomized controlled trial (RCT) examining the effect of iCPR-guided RN care for low acuity patients with ARI. The primary hypothesis to be tested …

Ethiopian Residents’ Attitudes Toward Dermatology Research: A Survey Study, Rishab R. Revankar, Heli A. Patel, Joo Yeon Shin, Alice B. Gottlieb, Loren D. Krueger, Benjamin K. Stoff

Student Papers, Posters & Projects

Dermatology programs in resource-limited settings manage high patient volumes.1 Trainees have extensive clinical responsibilities, which may preclude engaging in research. Programs in such settings may lack the infrastructure to provide adequate support. At the Department of Dermatovenereology at the University of Gondar in Ethiopia, residents anecdotally report a high caseload and lack of resources, including time, to pursue research. Members of Emory and Mount Sinai Dermatology designed and delivered a 30-minute presentation about research design and methods. Residents were surveyed pre- and postintervention about their attitudes toward pursuing dermatology research during residency

Direct Cohort: An Ncorp Longitudinal Observational Trial For Disparities In Results Of Immune Checkpoint Inhibitor Treatment Between Black And White Cancer Patients, Song Yao, Christine B. Ambrosone, Lori Sakoda, Igor Puzanovci, Eva Culakova, Michelle Janelsins, Warren Davis, Thaer Khoury, Elisa Rodriguez, Shipra Gandhi, Allison Magnuson, Guilherme Cantuaria, Jennifer M. Suga, Rajasree P. Chowdry, Lawrence H. Kushi, Karen Mustian, Gary R. Morrow, Charles Kamen

School of Medicine Faculty Publications

38th Annual Meeting of the Society for Immunotherapy of Cancer's, SITC 2023, November 1 -5, 2023, San Diego, CA

Appropriateness Of Antibiotic Prescribing Varies By Clinical Services At United States Children's Hospitals., Devin T. Diggs, Alison C. Tribble, Rebecca G. Same, Jason G. Newland, Brian R. Lee, Sharing Antimicrobial Reports For Pediatric Stewardship (Sharps) Collaborative

Manuscripts, Articles, Book Chapters and Other Papers

OBJECTIVE: To describe patterns of inappropriate antibiotic prescribing at US children's hospitals and how these patterns vary by clinical service.

DESIGN: Serial, cross-sectional study using quarterly surveys.

SETTING: Surveys were completed in quarter 1 2019-quarter 3 2020 across 28 children's hospitals in the United States.

PARTICIPANTS: Patients at children's hospitals with ≥1 antibiotic order at 8:00 a.m. on institution-selected quarterly survey days.

METHODS: Antimicrobial stewardship physicians and pharmacists collected data on antibiotic orders and evaluated appropriateness of prescribing. The primary outcome was percentage of inappropriate antibiotics, stratified by clinical service and antibiotic class. Secondary outcomes included reasons for inappropriate use …

Strategies For Culturally Safe Research With Native American Communities: An Integrative Review, Teresa Brockie, Kyle X. Hill, Patricia Davidson, Ellie Decker, Lydia Koh Krienke, Katie E. Nelson, Natalie Nicholson, Alicia M. Werk, Deborah Wilson, Deana Around Him

Indigenous Health Faculty Publications

Background: A history of unethical research and deficit-based paradigms have contributed to profound mistrust of research among Native Americans, serving as an important call to action. Lack of cultural safety in research with Native Americans limits integration of cultural and contextual knowledge that is valuable for understanding challenges and making progress toward sustainable change. Aim: To identify strategies for promoting cultural safety, accountability, and sustainability in research with Native American communities. Method: Using an integrative review approach, three distinct processes were carried out: (1) appraisal of peer-reviewed literature (Scopus, PubMed, and ProQuest), (2) review of grey literature (e.g. policy documents …

Prevalence And Characteristics Of Diagnostic Error In Pediatric Critical Care: A Multicenter Study, Christina L Cifra, Jason W Custer, Craig M Smith, Kristen A Smith, Dayanand N Bagdure, Jodi Bloxham, Emily Goldhar, Stephen M Gorga, Elizabeth M Hoppe, Christina D Miller, Max Pizzo, Sonali Ramesh, Joseph Riffe, Katharine Robb, Shari L Simone, Haley D Stoll, Jamie Ann Tumulty, Stephanie E Wall, Katie K Wolfe, Linder Wendt, Patrick Ten Eyck, Christopher P Landrigan, Jeffrey D Dawson, Heather Schacht Reisinger, Hardeep Singh, Loreen A Herwaldt

Faculty, Staff and Students Publications

Objectives: Effective interventions to prevent diagnostic error among critically ill children should be informed by diagnostic error prevalence and etiologies. We aimed to determine the prevalence and characteristics of diagnostic errors and identify factors associated with error in patients admitted to the PICU.

Design: Multicenter retrospective cohort study using structured medical record review by trained clinicians using the Revised Safer Dx instrument to identify diagnostic error (defined as missed opportunities in diagnosis). Cases with potential errors were further reviewed by four pediatric intensivists who made final consensus determinations of diagnostic error occurrence. Demographic, clinical, clinician, and encounter data were also …

Sex And Gender In Copd And Asthma, Joan B Soriano, Francesca Polverino

Faculty, Staff and Students Publications

No abstract provided.

P2y2 Purinergic Receptor Gene Deletion Protects Mice From Bacterial Endotoxin And Sepsis-Associated Liver Injury And Mortality, Athis R Arunachalam, Sanju S Samuel, Arunmani Mani, Janielle P Maynard, Kelsey M Stayer, Eric Dybbro, Subapradha Narayanan, Aalekhya Biswas, Saliha Pathan, Krishnakant Soni, Abu Hena Mostafa Kamal, Chandra Shekar R Ambati, Nagireddy Putluri, Moreshwar S Desai, Sundararajah Thevananther

Faculty, Staff and Students Publications

The liver plays a significant role in regulating a wide range of metabolic, homeostatic, and host-defense functions. However, the impact of liver injury on the host's ability to control bacteremia and morbidity in sepsis is not well understood. Leukocyte recruitment and activation lead to cytokine and chemokine release, which, in turn, trigger hepatocellular injury and elevate nucleotide levels in the extracellular milieu. P2Y2 purinergic receptors, G protein-coupled and activated by extracellular ATP/UTP, are expressed at the cell surface of hepatocytes and nonparenchymal cells. We sought to determine whether P2Y2 purinergic receptor function is necessary for the maladaptive host response to …

The Relationship Between Parental Trauma History And Perceptions Regarding Their Child’S Healthcare And Utilization Of Healthcare Services, Krishna Patel

Theses and Dissertations

Abstract

TITLE: The Relationship Between Parental Trauma History and Perceptions Regarding Their Child’s Healthcare and Utilization of Healthcare Services

Adverse child events (ACEs) have been associated with a number of physical and mental health problems and have also been linked to increased health care utilization. While parents who have an ACE history may tend to seek healthcare services for themselves, limited studies have examined the impact of their trauma history on seeking healthcare services for their child. Healthcare utilization may also depend on the parents’ level of health anxiety, as well as their anxiety about their child’s health status. This …

Coxarthrosis Etiology Influences The Patients’ Quality Of Life In The Preoperative And Postoperative Phase Of Total Hip Arthroplasty, Madalin Bulzan, Simona Cavalu, Amir Mohamed Abdelhamid, Calin Tudor Hozan, Florica Voiţă-Mekeres

Journal of Mind and Medical Sciences

Background. In orthopedics, the patients’ quality of life relative to the preoperative and postoperative phase is referred with a low impact compared to other branches of medicine. In this context, our interest focused on assessing the quality of life in patients with traumatic and non-traumatic coxarthrosis by longitudinally following the evolution of the patients. Materials and Methods. The well-established instrument Short Form Survey SF-36 was applied in a retrospective study, conducted on a cohort of 203 participants who underwent THA (Total Hip Arthroplasty). Statistical analysis was generated using GraphPad Prism (version 9.5.1). Results. In the pre-operative phase, physical functioning was …

The Influence Of Hospital Brand Image On Patient's Decision To Choose Hospital: Literature Review, Akhada Maulana, Dumilah Ayuningtyas

Jurnal ARSI : Administrasi Rumah Sakit Indonesia

People nowadays with different characteristics are very selective when choosing medical services. Hospitals as service providers are expected to have a good brand image which is the patient's perception of a brand. It is built by trust in care and knowledge about the hospital. The hospital's brand image makes patients recognize and differentiate them from others. Patient selection of health care facilities is a complex process. The brand image expected to had a direct effect on hospital selection. This article explains the influence of hospital brand image on patients' decisions to choose a hospital. The method used is a literature …

Patient Involvement And Communication Council, Angela Murphy, Laura Gooseberry, Becca Austin, Rob Behrendt, Lara Miskevich

2023 Patient Advisor Retreat

Patient-Centered Care (nothing about me without me) is the best approach to improve outcomes and provide value to each patient. The Council is involved in the following: Act as champions of patient experience andbring ideas, thoughts, and opinions on various topics and processes. Review patient and family communications to ensure engagement in health care services. Provide feedback regarding communication gaps between patients and providers. Revise and improve materials to be understood by patients and their caregivers.

Using Storytelling To Share Lived Experiences With Maternal Mental Health (Mama), Sara Santarossa, Amy Loree, Courtney Latimer, Wendy Corriveau, Sara Mertz, Hailey Maddox, Leah M. Copeland, Dana Murphy, Ashley B. Redding

2023 Patient Advisor Retreat

Mental health conditions are a top medical complication of pregnancy and childbirth and are associated with a range of adverse maternal and child outcomes. Approximately 1 in 7 to 1 in 4 birthing people experience symptoms of a mental health condition during pregnancy or postpartum, yet few are diagnosed or treated. There remain critical knowledge gaps and significant challenges to adequately addressing maternal mental health. Project aims to use storytelling to share diverse perspectives on MAternal MentAl health (MAMA), build capacity and engagement for patient centered research by sharing these stories in a Storytelling Symposium, and with the aid of …

Bump: Burnout Mitigation In Physician Trainees, Jacqueline Pflaum-Carlson, Sara Santarossa, Lisa Mclean, Julie A. Hamilton, Dana Murphy, Ashley B. Redding

2023 Patient Advisor Retreat

Physician burnout affects healthcare organizations at every level and has been associated with higher self-reported errors, increased turnover, and has a negative impact on patient care; it is estimated that tens of thousands of Americans die each year as a result ofpreventable medical errors. This project seeks to reduce the symptoms of physician burnout by exploring Acceptance Commitment Therapy (ACT) compared to Body Mapping as effective interventions in preventing and mitigating burnout in physician trainees at Henry Ford Health (HFH) in Detroit, Michigan.

Our Contributions To The Hermelin Brain Tumor Center (Hbtc), Megan Sauer, Marc Betman, Ron Leach, Mike Coughlin, Jeni Barry, Dominik Mackowski, Lisa Scarpace, Nestelynn Gay

2023 Patient Advisor Retreat

The Hermelin Brain Tumor Center Patient and Family Advisory Council is comprised of patients and care partners who have generously agreed to come together to share their experiences and ideas. Mission Statement: Our goal is to drive patient and caregiver education, innovation, research, and success to continue to be a center of excellence. We aim to amplify the strengths of the Hermelin Brain Tumor Center by sharing our combined experience as patients, caregivers, and clinicians to its continual improvement and development.

Pursuing Equity In Patient Care (Pepc), Linda Stechison, Jaquetta Hinton, Marla R. Gorosh, Kimberleydawn Wisdom

2023 Patient Advisor Retreat

Participating on the PEPC Committee is an opportunity to observe the exchange of information with leaders who are in positions to act on Quality Improvement (QI) projects/clinical research(CR) results to expand scope, encourage spread, and share resources. As Patient Advisors we use the lenses of our personal identities, work history, and life experiences to provide perspective for the patients’ voices. We see the barriers of the patient-clinician relationship that don’t address the power differential and make assumptions (unconscious bias) that affect adherence and outcomes of care.

Steps Pfac: Seniors Using Technology To Engage In Pain Self-Management, Lisa D. Landvogt, Leslie Grijalva, Tracie Mason, Jessica Judson, Courtney Latimer, Jaye Clement, Kimberlydawn Widsom, Tashfia Jilu, Sara Nguyen, Rebecca Lindsay, Mary Javenic

2023 Patient Advisor Retreat

STEPS stands for Seniors using Technology to Engage in Pain Self-management. We are testing to see if a pain self-management program can help people live better with chronic pain and reduce pain’s impact on their lives. Participants will: Complete three 60-minute telephone surveys Baseline, 2-month follow-up, and 12-month follow-up. Be randomly placed into one of two groups (50/50 chance): Intervention Group: A 7-week program with web-based videos and weekly telephone sessions led by a Community Health Worker. Control Group: A control group that receives program materials & a half-day workshop after the final survey.

Experienced Transformation Patient & Family Advisory Council, John Bollinger, Thomas Eisenmann, Missy Ewald, Julie Goldstein-Dunn, Ally Hunter, Jennifer Kindseth, Shivani Mehta, Vanessa Mona, Stephanie Ryan, Courtney Stevens, Rajitha Viswaraju

2023 Patient Advisor Retreat

Providing Patient-Centered Care (Nothing about me without me) is the best approach to improving outcomes and providing value to each patient. This council works on initiatives and process improvement around pre-visit, onsite visit, and post-visit communication and delivery. Additional Henry Ford Health priorities are to leverage existing or new digital solutions that facilitate patient access, strengthen existing referral channels and growing new ones with potential future partners, assist patients with understanding and paying their health expenses, and better manage total per member per month cost through patient/member engagement in their wellness and care.

Improving Research Is A Multipronged Collaborative Approach Reliant On "Expert" Humility And Respect, Philip Cheng, Andrew Bossick, Ashley B. Redding

2023 Patient Advisor Retreat

Our project goal is to bring together Henry Ford health sciences researchers and community members to promote the engagement of diverse patient perspectives. This poster highlights current initiatives pertaining to the integration of diverse perspectives into the research process to enhance our science at the group, system, and NIH level.