National Record Research Articles

Exploring Bullshit in the Field of Medical Informatics: A Critical Perspective.

Medical informatics continues to face significant challenges in establishing itself as a fully recognized scientific discipline. This lack of recognition can sometimes foster endeavors that, while appealing to uninformed audiences, may lack substantive scientific merit. This paper examines the concept of "bullshit" within the field, distinguishing between two forms: intentional misrepresentation (F-bullshit) and uncritical proliferation of assertions as truth (C-bullshit). By analyzing two case studies - the implementation of a national electronic health record (EHR) system in Switzerland and the use of patient-reported outcomes (PROMs) - we demonstrate how these types of bullshit sometimes emerge in medical informatics. We argue that a thorough investigation into the epistemological foundations of the discipline is essential for clearly delineating authentic scientific progress from superficial or misleading representations that may only mimic scientific rigor.

Exploring Bullshit in the Field of Medical Informatics: A Critical Perspective.

Medical informatics continues to face significant challenges in establishing itself as a fully recognized scientific discipline. This lack of recognition can sometimes foster endeavors that, while appealing to uninformed audiences, may lack substantive scientific merit. This paper examines the concept of "bullshit" within the field, distinguishing between two forms: intentional misrepresentation (F-bullshit) and uncritical proliferation of assertions as truth (C-bullshit). By analyzing two case studies - the implementation of a national electronic health record (EHR) system in Switzerland and the use of patient-reported outcomes (PROMs) - we demonstrate how these types of bullshit sometimes emerge in medical informatics. We argue that a thorough investigation into the epistemological foundations of the discipline is essential for clearly delineating authentic scientific progress from superficial or misleading representations that may only mimic scientific rigor.

Large-Scale Evaluation and Liver Disease Risk Prediction in Finland's National Electronic Health Record System: Feasibility Study Using Real-World Data.

Globally, the incidence and mortality of chronic liver disease are escalating. Early detection of liver disease remains a challenge, often occurring at symptomatic stages when preventative measures are less effective. The Chronic Liver Disease score (CLivD) is a predictive risk model developed using Finnish health care data, aiming to forecast an individual's risk of developing chronic liver disease in subsequent years. The Kanta Service is a national electronic health record system in Finland that stores comprehensive health care data including patient medical histories, prescriptions, and laboratory results, to facilitate health care delivery and research. This study aimed to evaluate the feasibility of implementing an automatic CLivD score with the current Kanta platform and identify and suggest improvements for Kanta that would enable accurate automatic risk detection. In this study, a real-world data repository (Kanta) was used as a data source for "The ClivD score" risk calculation model. Our dataset consisted of 96,200 individuals' whole medical history from Kanta. For real-world data use, we designed processes to handle missing input in the calculation process. We found that Kanta currently lacks many CLivD risk model input parameters in the structured format required to calculate precise risk scores. However, the risk scores can be improved by using the unstructured text in patient reports and by approximating variables by using other health data-like diagnosis information. Using structured data, we were able to identify only 33 out of 51,275 individuals in the "low risk" category and 308 out of 51,275 individuals (<1%) in the "moderate risk" category. By adding diagnosis information approximation and free text use, we were able to identify 18,895 out of 51,275 (37%) individuals in the "low risk" category and 2125 out of 51,275 (4%) individuals in the "moderate risk" category. In both cases, we were not able to identify any individuals in the "high-risk" category because of the missing waist-hip ratio measurement. We evaluated 3 scenarios to improve the coverage of waist-hip ratio data in Kanta and these yielded the most substantial improvement in prediction accuracy. We conclude that the current structured Kanta data is not enough for precise risk calculation for CLivD or other diseases where obesity, smoking, and alcohol use are important risk factors. Our simulations show up to 14% improvement in risk detection when adding support for missing input variables. Kanta shows the potential for implementing nationwide automated risk detection models that could result in improved disease prevention and public health.

Understanding public trust in national electronic health record systems: A multi-national qualitative research study.

Having public trust in national electronic health record systems (NEHRs) is crucial for the successful implementation and participation of NEHRs within a nations healthcare system. Yet, a lack of conceptual clarity precludes healthcare policymakers from incorporating trust to the fullest extent possible. In response, this study seeks to validate an existing framework for public trust in the healthcare system, which will help provide a clearer understanding of what constitutes public trust in NEHRs across members of the public in different countries, cultures, and contexts. Twenty-four focus groups were conducted in Austria, Germany, France, Italy, the Netherlands, and Switzerland with residents of each respective country to discuss their viewpoints on our public trust in NEHRs framework in order to validate said framework. Frameworks describing the causes and effects of public trust in NEHRs were created for each country studied. Across all countries, the frameworks remained similar to our base framework, highlighting our frameworks' robustness. Data security, privacy, and autonomy were consistently described as the most important aspects of public trust in NEHRs. Concurrently, health system actors, such as doctors, were found to have significant influence on NEHR implementation. Their influence, however, can either be beneficial or detrimental to public trust in NEHRs, depending on their actions and how the public perceives those actions. Additional results detail contextual insights into country-specific viewpoints and the role of healthcare stakeholders in public trust in NEHRs. The results showcase the differences and similarities in which different populations across Europe view trust in NEHRs in the context of our framework. These findings present public trust frameworks in the context of NEHRs for the study countries. These frameworks can assist stakeholders in obtaining a comprehensive understanding of the complexity of public trust in implementing and promoting their NEHRs, including measurements of public trust.

Machine learning to improve HIV screening using routine data in Kenya.

Optimal use of HIV testing resources accelerates progress towards ending HIV as a global threat. In Kenya, current testing practices yield a 2.8% positivity rate for new diagnoses reported through the national HIV electronic medical record (EMR) system. Increasingly, researchers have explored the potential for machine learning to improve the identification of people with undiagnosed HIV for referral for HIV testing. However, few studies have used routinely collected programme data as the basis for implementing a real-time clinical decision support system to improve HIV screening. In this study, we applied machine learning to routine programme data from Kenya's EMR to predict the probability that an individual seeking care is undiagnosed HIV positive and should be prioritized for testing. We combined de-identified individual-level EMR data from 167,509 individuals without a previous HIV diagnosis who were tested between June and November 2022. We included demographics, clinical histories and HIV-relevant behavioural practices with open-source data that describes population-level behavioural practices as other variables in the model. We used multiple imputations to address high rates of missing data, selecting the optimal technique based on out-of-sample error. We generated a stratified 60-20-20 train-validate-test split to assess model generalizability. We trained four machine learning algorithms including logistic regression, Random Forest, AdaBoost and XGBoost. Models were evaluated using Area Under the Precision-Recall Curve (AUCPR), a metric that is well-suited to cases of class imbalance such as this, in which there are far more negative test results than positive. All model types demonstrated predictive performance on the test set with AUCPR that exceeded the current positivity rate. XGBoost generated the greatest AUCPR, 10.5 times greater than the rate of positive test results. Our study demonstrated that machine learning applied to routine HIV testing data may be used as a clinical decision support tool to refer persons for HIV testing. The resulting model could be integrated in the screening form of an EMR and used as a real-time decision support tool to inform testing decisions. Although issues of data quality and missing data remained, these challenges could be addressed using sound data preparation techniques.

Two new species of Ceratocanthinae from the Dayao Mountains, Guangxi, China (Coleoptera: Hybosoridae)

Two new species of ceratocanthine beetles, namely Cyphopisthes erlangshen sp. nov. and Madrasostes lini sp. nov., are herein described from the Dayao Mountains, Guangxi, China. The former represents a new national record for the genus Cyphopisthes Gestro, 1899. Illustrations of the habitus and diagnostic characters of both species are provided.

Revamping Pace Distribution: A Case Study on Elevating the Men's 400 m Track and Field Japanese National Record After 32 Years.

Chiba, Y, Sato, K, Yoshimoto, T, Ohnuma, H, Yamanaka, R, Takahashi, K, Kobayashi, K, Matsubayashi, T, and Takai, Y. Revamping pace distribution: A case study on elevating the men's 400 m track and field Japanese national record after 32 years. J Strength Cond Res 39(4): e610-e615, 2025-Many studies have investigated the 400-m sprint, and the optimal pacing strategy is subject to debate. Little information is available regarding the effects of changes in the pacing strategy on running speed and spatiotemporal variables in the official 400-m race. This case study analyzed changes in running speed and spatiotemporal variables of a Japanese elite long sprinter who set a new Japanese national record in the 400-m race by modifying his pace distribution based on the analysis of his previous races and the performances of world-class long sprinters. To revamp his pace distribution, 25 preceding races (ranging from 45.47 to 46.95 seconds) were analyzed, spanning from June 2015 to June 2023. The independent variables were the 50-m split time, average running speed, percentage of the 50-m split time relative to the 400-m record, step length, and step frequency. K.S. broke his own record by modifying the pacing distribution based on the development of his previous race and the world-class long sprinters. The modified pacing strategy increased running speed in the 200- to 300-m section. Step lengths were longer throughout the 400 m, and step frequencies were higher in the last 200 m than before the alteration in the pace distribution. Modifying the pacing strategy from leading to driving may enhance the personal records of long sprinters. This improvement is attributed to the maintenance of longer step lengths over the entire 400-m range and an increase in the step frequency in the last 200 m.

[Translated article] National registry and analysis of pharmaceutical interventions in critical care units: PHARMACRITIC study

[Translated article] National registry and analysis of pharmaceutical interventions in critical care units: PHARMACRITIC study

Receipt of medications for opioid use disorder among rural and urban veterans health administration patients.

Receipt of medications for opioid use disorder among rural and urban veterans health administration patients.

Checklist and bilingual key to the genera of Scutelleridae (Hemiptera: Heteroptera) from Mexico, with new distribution records for the state of Oaxaca.

For the first time, we provide a checklist and a bilingual key to the genera of Scutelleridae (Hemiptera: Heteroptera) from Mexico, with new distribution records for the state of Oaxaca. The scutellerid fauna of Mexico is comprised of 35 species, two subspecies, 14 genera and two subfamilies, of which seven species are endemic. The best-represented genus in Mexico is Symphylus with eight species. The states of Veracruz and Oaxaca have the highest richness with 17 and 15 species, respectively. The new records for Oaxaca correspond to the species: Camirus moestus (Stål), Orsilochides scurrilis (Stål), Stethaulax marmorata (Say), Symphylus caribbeanus Kirkaldy (all Pachycorinae) and Augocoris gomesii Burmeister (Scutellerinae). We add new locality records for Pachycoris klugii Burmeister and Tetyra antillarum Kirkaldy in Oaxaca. We provide data on the possible coprophagy of Sphyrocoris obliquus (Germar) (Pachycorinae). Stethaulax marmorata is a new state and national record. Also, we document new associations of scutellerids with plants and, a new host record for T. antillarum.

Trends in Physician Electronic Health Record Time and Message Volume

This cohort study uses national electronic health record data to assess patient medical advice request message volume and the time physicians spend in the records.

Patterns of health service use before and after diagnosis of endometriosis: a data linkage prospective cohort study.

What are the patterns of health service use (HSU) before and after endometriosis diagnosis? Women with endometriosis had higher rates of visits to general practitioners (GPs), specialists, and diagnostic imaging before and after diagnosis compared to those without the condition; however, after diagnosis, their visits to GPs and specialists other than obstetricians/gynaecologists decreased compared to before, while visits to obstetricians/gynaecologists and use of diagnostic imaging increased. Women with endometriosis have higher rates of healthcare use compared to those without the condition; however, no longitudinal study has examined patterns of HSU over a prolonged period before and after diagnosis. The Australian Longitudinal Study on Women's Health linked to a national administrative health record. A total of 30473 women, born in 1973-1978 and 1989-1995, from two cohorts with data collected from 1996 to 2021, as online or postal questionnaires. Women with endometriosis were identified using the self-report surveys and their administrative health records. A control group of women without endometriosis was randomly selected and age-matched with women with endometriosis. The final sample included 9545 women from the 1973-1978 cohort (1909 cases, 7636 controls) and 7510 from the 1989-1995 cohort (1502 cases, 6008 controls). Women's HSU was assessed using the Medicare Benefits Schedule database. A random intercept zero-inflated negative binomial model was used to compare outcomes between cases and controls, addressing skewed data, over-dispersion, and excess zeros. In both cohorts, women with endometriosis had a higher level of HSU, both before and after diagnosis, compared with those without the condition. For the 1973-1978 cohort, women with endometriosis had a higher rate of visits to GPs before and after diagnosis (adjusted incidence rate ratio: 1.19, 95% CI 1.14, 1.23 and 1.24, 95% CI 1.19, 1.30, respectively), specialists other than obstetricians/gynaecologists (1.50, 95% CI 1.40, 1.61, and 1.36, 95% CI 1.27, 1.46), and for diagnostic imaging (1.15, 95% CI 1.10, 1.21, and 1.20, 95% CI 1.15, 1.26). The average number of these visits remained consistent in the early years, peaked around 3 years before diagnosis, and then partly declined post-diagnosis, to later stabilize at a higher level than those without the condition. Following the diagnosis, women with endometriosis had a higher number of visits to obstetricians/gynaecologists (1.11, 95% CI 1.05, 1.17) than their matched controls, with a marked increase in the first 6 years post-diagnosis, but gradually returned to same levels as the control group. After diagnosis, women with endometriosis had a lower rate of visits to GPs (0.95, 95% CI 0.93, 0.98) and specialists other than obstetricians/gynaecologists (0.88, 95% CI 0.82, 0.93) compared to before their diagnosis, while they had a higher rate of visits to obstetricians/gynaecologists (1.09, 95% CI 1.01, 1.18) and diagnostic imaging (1.07, 95% CI 1.01, 1.14). Similar patterns of HSU were observed in the 1989-1995 cohort, regardless of whether surgically confirmed or clinically suspected cases of endometriosis were used, though the evidence for changes in specific HSU before and after diagnosis was weaker. Approximately half of the women with endometriosis were clinically suspected cases without laparoscopic confirmation, which may result in an overestimation of prevalence and introduce the risk of misdiagnosis, potentially influencing clinical management and research findings. The continued high level of HSU among women with endometriosis, even over a decade after diagnosis, suggests that they have substantially greater healthcare needs than other women. The distinct patterns of the use of healthcare in the years before and after endometriosis diagnosis can support efforts to improve diagnosis, management, and treatment outcomes for patients and to reduce healthcare costs. The Australian Longitudinal Study on Women's Health is funded by the Australian Government Department of Health and Aged Care. G.D.M. and G.M. are Australian National Health and Medical Research Council Leadership Fellows (GNT2009577 and GNT1177194). D.G.G. was funded by MRFF EndoAIMM (RFEHP100126). Funding sources had no role in the study design, data analysis, interpretation, or manuscript writing. The authors have no conflict of interest to declare. N/A.

Cost of illness of Heart Valve Diseases (HVDs): A real-world analysis in Italy.

Heart valve diseases constitute a significant public health challenge with substantial clinical and economic implications. The ageing population, coupled with advancements in surgical techniques, has led to increased hospitalizations for cardiac valve interventions over the past decade. Despite progress, the economic burden of heart valve diseases remains underexplored, particularly in the context of the Italian healthcare system. This study aims to comprehensively assess the economic burden of heart valve diseases in Italy through a real-world analysis. Using data from the national Italian Hospital Discharge Records (SDO), we identified the number of adult patients undergoing interventions on the aortic, mitral, and tricuspid valves, along with the associated costs borne by the National Health System. Additionally, we estimated indirect costs by analyzing social security benefit applications related to valve diseases from 2016 to 2019. A notable rise in hospitalizations for cardiac valve interventions, particularly for the aortic (+53.3%) and mitral valves (+29.5%) was revealed through the study period. In-hospital mortality rates declined, reflecting advancements in perioperative care. The economic burden of heart valve diseases in Italy was substantial, with hospitalization costs reaching €808 million in 2018. Social security benefit applications also increased, adding an annual cost of €29 million. Heart valve diseases represent a growing clinical and socio-economic challenge in Italy. This study underscores the imperative for a multidisciplinary approach to effectively manage these conditions. Emphasizing prevention, early diagnosis, and timely interventions is crucial to mitigate the economic impact and enhance the quality of life for patients.

Rates, causes and predictors of all-cause and avoidable mortality in 514 878 adults with and without intellectual disabilities in Scotland: a record linkage national cohort study

BackgroundStudies on avoidable mortality in adults with intellectual disabilities are limited, as are studies on causes of death.ObjectivesWe aimed to quantify mortality rates, and causes, and identify factors (i.e., age,...

Vaccine Effectiveness Among 5- to 17-year-old Individuals with Prior SARS-CoV-2 Infection: An EHR-Based Target Trial Emulation Study from the RECOVER Project.

Prior studies have demonstrated the effectiveness of COVID-19 vaccines in children and adolescents. However, the benefits of vaccination in these age groups with prior infection remain underexplored. To evaluate the effectiveness of COVID-19 vaccination in preventing reinfection with various Omicron subvariants (BA.1/2, BA.4/5, XBB, and later) among 5- to 17-year-olds with prior SARS-CoV-2 infection. A target trial emulation through nested designs with distinct study periods. The study utilized data from the Research COVID to Enhance Recovery (RECOVER) initiative, a national electronic health record (EHR) database comprising 37 U.S. children's hospitals and health institutions. Individuals aged 5-17 years with a documented history of SARS-CoV-2 infection prior to the study start date during a specific variant-dominant period (Delta, BA.1/2, or BA.4/5) who received a subsequent dose of COVID-19 vaccine during the study periods were compared with those with a documented history of infection who did not receive SARS-CoV-2 vaccine during the study period. Those infected within the Delta-Omicron composite period (December 1, 2021, to December 31, 2021) were excluded. The study period was from January 1, 2022, to August 30, 2023, and focused on adolescents aged 12 to 17 years and children aged 5 to 11 years. At least received one COVID-19 vaccination during the study period vs. no receipt of any COVID-19 vaccine during the study period. The primary outcome is documented SARS-CoV-2 reinfection during the study period (both asymptomatic and symptomatic cases). The effectiveness of the COVID-19 vaccine was estimated as (1-hazard ratio) *100%, with confounders adjusted by a combination of propensity score matching and exact matching. The study analyzed 87,573 participants during the BA.1/2 period, 229,326 during the BA.4/5 period, and 282,981 during the XBB or later period. Among vaccinated individuals, significant protection was observed during the BA.1/2 period, with effectiveness rates of 62% (95% CI: 38%-77%) for children and 65% (95% CI: 32%-81%) for adolescents. During the BA.4/5 period, vaccine effectiveness was 57% (95% CI: 25%-76%) for children, but not statistically significant for adolescents (36%, 95% CI: -16%-65%). For the XBB period, no significant protection was observed in either group, with effectiveness rates of 22% (95% CI: -36%-56%) in children and 34% (95% CI: -10%-61%) in adolescents. COVID-19 vaccination provides significant protection against reinfection for children and adolescents with prior infections during the early and mid-Omicron periods. This study also highlights the importance of addressing low vaccination rates in pediatric populations to enhance protection against emerging variants. Question: Does COVID-19 vaccination protect against reinfection with Omicron subvariants (BA.1/2, BA.4/5, XBB, and later) among children and adolescents aged 5-17 years with prior SARS-CoV-2 infection?Findings: COVID-19 vaccination significantly reduced the risk of reinfection during the BA.1/2 period, with effectiveness rates of 62% in children and 65% in adolescents. During the BA.4/5 period, vaccination provided moderate protection in children, with effectiveness rates of 57%, but the effectiveness in adolescents (36%) was not statistically significant. For the XBB period and later subvariants, vaccination did not show significant protection in either group.Meaning: COVID-19 vaccination offered meaningful protection against reinfection in pediatric populations during earlier Omicron periods but became less effective with later emerging subvariants, highlighting the challenges of sustaining vaccine effectiveness as the virus continues to evolve.

Exploring the Development of Canadas Smart Healthcare System in the Digital Era

In the digital era, the need for a robust and efficient healthcare system is paramount, particularly for developed countries like Canada. This paper explores the feasibility and potential benefits of integrating smart healthcare solutions into the Canadian healthcare system to address its current shortcomings. Despite Canadas comprehensive healthcare services, issues such as long waiting times, a shortage of medical professionals, and insufficient coverage in remote areas persist. The research utilizes a combination of literature review and case study methods to analyze existing problems and the impact of smart technologies in healthcare. By proposing the implementation of intelligent triage systems, a unified national electronic health record (EHR), and extensive telemedicine services, this study aims to enhance healthcare accessibility, improve service delivery, and increase overall system efficiency. The anticipated outcome is a more responsive healthcare system that can better meet the needs of Canadas diverse population. The findings will contribute to ongoing discussions and development strategies within Canadian healthcare policy circles.

Genetic parameters for milk production traits of Simmental cows with random regression test-day model.

Genetic parameters for milk production traits of Simmental cows with random regression test-day model.

Severity and Long-Term Mortality of COVID-19, Influenza, and Respiratory Syncytial Virus

SARS-CoV-2, influenza, and respiratory syncytial virus (RSV) contribute to many hospitalizations and deaths each year. Understanding relative disease severity can help to inform vaccination guidance. To compare disease severity of COVID-19, influenza, and RSV among US veterans. This retrospective cohort study analyzed national US Veterans Health Administration electronic health record data of nonhospitalized veterans who underwent same-day testing for SARS-CoV-2, influenza, and RSV, and were diagnosed with a single infection between August 1, 2022, and March 31, 2023, or between August 1, 2023, and March 31, 2024. Infection with SARS-CoV-2, influenza, or RSV. Following inverse probability weighting, the cumulative incidence and risk differences (RDs) were calculated for the primary outcomes of 30-day hospitalization, intensive care unit admission, and death, as well as the secondary outcome of long-term death extending through 180 days. Among 68 581 patients included in the 2022 to 2023 cohort (6239 [9.1%] with RSV, 16 947 [24.7%] with influenza, and 45 395 [66.2%] with COVID-19) and 72 939 in the 2023 to 2024 cohort (9748 [13.4%] with RSV, 19 242 [26.4%] with influenza, and 43 949 [60.3%] with COVID-19), the median (IQR) age was 66 (53-75) years, and 123 090 (87.0%) were male. During the 2023 to 2024 season, the 30-day risk of hospitalization was similar for COVID-19 (16.2%) and influenza (16.3%) but lower for RSV at 14.3% (RD for COVID-19 vs RSV, 1.9% [95% CI, 0.9%-2.9%]; RD for influenza vs RSV, 2.0% [95% CI, 0.8%-3.3%]). The 30-day risk of death during the 2022 to 2023 season was slightly higher for COVID-19 (1.0%) compared with influenza (0.7%) (RD, 0.4% [95% CI, 0.1%-0.6%]) or RSV (0.7%) (RD, 0.4% [95% CI, 0.1%-0.6%]) but similar during the 2023 to 2024 season. Mortality risk at 180 days was higher for COVID-19 during both seasons (2023-2024 RD for COVID-19 vs influenza, 0.8% [95% CI, 0.3%-1.2%]; RD for COVID-19 vs RSV, 0.6% [95% CI, 0.1%-1.1%]). Higher mortality in both seasons was observed for veterans without COVID-19 vaccination in the previous year compared to veterans without seasonal influenza vaccination. In contrast, among groups vaccinated against their respective infections, there were no mortality differences at any time point between COVID-19 and influenza. This cohort study showed that, during the 2022 to 2023 season, infection with SARS-CoV-2 was associated with more severe disease outcomes than influenza or RSV, whereas differences were less pronounced during the 2023 to 2024 season. During both seasons, RSV remained a milder illness, whereas COVID-19 was associated with higher long-term mortality. Vaccination attenuated differences in disease severity and long-term mortality.

Consumer perspectives on the national electronic health record and barriers to its adoption in Germany: does health policy require a change in communication?

BackgroundThe national health record (ePA) was introduced January 1st, 2021 in Germany and is available to every person insured under statutory health insurance. This study investigated the acceptance and expectations of the national health record in Germany, focusing on consumer perspectives, expectations, barriers, information needs, and communication aspects.MethodsAn exploratory, observational, cross-sectional online survey was conducted one year after ePA introduction, followed by descriptive statistical analysis.ResultsThe top three ePA use cases were medical document collection, simplified data exchange between medical institutions, and emergency medical information. Adoption barriers included lack of information and access, privacy concerns, and perceived lack of necessity. Participants that felt informed about the ePA, reported they received information primarily from health insurances, the media, and educational or professional sources, mainly through printed brochures, social media, or via emails. Most participants (86.5%) preferred being informed through conversations, particularly with health insurance providers (81.5%) and doctors (61.0%). Written information was highly desired (94.5%), preferably via email or information letters/flyers. However, more than half of the participants (55.6%) reported being uninformed about the ePA introduction.ConclusionThe study revealed a communication gap between providers and consumers, leading to a low acceptance rate of digital health technologies. Comparisons with other countries showed low adoption rates for opt-in systems. The authors suggest changing communication strategies, given users prefer direct information from doctors or health insurance companies. Adopting an opt-out system with professional social media and marketing campaigns could increase nationwide ePA adoption.

Climate Change, Coastal Heritage Digitization, and Local Community Engagement at the Ruins of Kilwa Kisiwani World Heritage Site, Tanzania

ABSTRACT Kilwa Kisiwani is a UNESCO World Heritage Site on the coast of Tanzania. Monuments such as the Great Mosque and Husuni Kubwa, along with shipwrecks, ceramics, and beads, testify to the growth of Swahili culture and commerce from the late 1st millennium a.d. until the 19th century a.d. This heritage is threatened by climate change involving rising sea levels, increased vegetation growth, and tropical cyclones causing erosion, flooding, altering marine ecosystems and resources, and saltwater intrusion into freshwater wells. Archaeological and paleoenvironmental evidence suggests previous climatic changes led to changing settlement patterns. Projects have been initiated, linked to a National Monument Record database, to digitize and record endangered intangible and tangible heritage, including training in drone surveys, underwater shipwreck recording, a mobile app, and excavation of water wells. These projects have a local community input that link with a museum, festivals, cultural tours, music videos, and local products to bring economic benefit and sustainable living.