Preparing Future Pediatric Care Providers with a Clinical Informatics Elective

Abstract

Background Clinical informatics (CI) has reshaped how medical information is shared, evaluated, and utilized in health care delivery. The widespread integration of electronic health records (EHRs) mandates proficiency among physicians and practitioners, yet medical trainees face a scarcity of opportunities for CI education.

Objectives We developed a CI rotation at a tertiary pediatric care center to teach categorical pediatric, pediatric–neurology, and medicine–pediatric residents foundational CI knowledge and applicable EHR skills.

Methods Created in 2017 and redesigned in 2020, a CI rotation aimed to provide foundational CI knowledge, promote longitudinal learning, and encourage real-world application of CI skills/tools. Led by a team of five physician informaticist faculty, the curriculum offers personalized rotation schedules and individual sessions with faculty for each trainee. Trainees were tasked with completing an informatics project, knowledge assessment, and self-efficacy perception survey before and after rotation. Paired t-test analyses were used to compare pre- and postcurriculum perception survey.

Results Thirty-one residents have completed the elective with their projects contributing to diverse areas such as medical education, division-specific initiatives, documentation improvement, regulatory compliance, and operating plan goals. The mean knowledge assessment percentage score increased from 77% (11.6) to 92% (10.6; p ≤ 0.05). Residents' perception surveys demonstrated improved understanding and confidence across various informatics concepts and tools (p ≤ 0.05).

Conclusion Medical trainees are increasingly interested in CI education and find it valuable. Our medical education curriculum was successful at increasing residents' understanding, self-efficacy, and confidence in utilizing CI concepts and EHR tools. Future data are needed to assess the impact such curricula have on graduates' proficiency and efficiency in the use of CI tools in the clinical workplace.

 

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Keywords

clinical informatics - pediatrics - training - residency - evaluation

Background and Significance

Electronic health records (EHRs) have been adopted in most settings; 78% of office-based physicians and nearly all nonfederal acute care hospitals (96%) use EHRs.[1] Biomedical or clinical informatics has developed as its own certified field of study as of 2011 with discoveries transforming the practice of medicine.[2] The focus of clinical informatics over the years has varied somewhat but patient safety and quality of care have remained central targets for intervention with recent contextual attention on health equity and access to care.[3] Despite the notable overlap of goals between clinical informatics and clinical medicine and affiliated fields, formal training in clinical informatics is not universal for medical and postgraduate trainees, who are entering the workforce underprepared for the evolving landscape of health information technology (IT).[4] A web-based survey by Briscoe et al demonstrated that among 160 trainees recruited at two U.S. training institutions, 81% of trainees agree or strongly agree that technology skills should be included in their medical curriculum. Trainees identified the EHR as one of the technology skills most important to learn about.[5] Nevertheless, other than American College of Graduate Medical Education (ACGME)-certified clinical informatics fellowships which culminate in board certification cosponsored by the American Boards of Pathology and Preventive Medicine, formal informatics training for medical trainees within the scope of their standard medical training curriculum has been limited to the fields of radiology and pathology and through individual program initiatives in other fields.[2] [6] [7] [8] [9]

Interestingly, the ACGME does not explicitly include clinical informatics content for family medicine residents. In contrast, internal medicine, pediatrics, and emergency medicine ACGME competencies include the use of IT as a means to optimize learning. Radiology and pathology educators have more explicitly addressed clinical informatics in their standard curriculum.[7] [10] In the most recent ACGME Pediatrics program requirement revision released in 2023, the ACGME added the requirement for pediatricians to stay current with advanced and emerging technologies and that residents “must demonstrate knowledge of … the application of information technologies and telehealth.” [11] Despite this emphasis, there have been only a handful of programs with published guidelines or model program descriptions in the literature.[12] [13] [14] [15] [16] Many of these programs require an application process[12] [15] [16] and some can be resource-intensive (large board-certified faculty educators, significant amount of protected teaching time, and stipends for residents).[12] [14] [15]

Previous initiatives aimed at advancing resident clinical informatics education have exhibited diverse approaches and strategies. The University of California-Los Angeles, for example, created a 2-year long curriculum taught by 21 physician faculty members. The program requires an application process.[12] University of North Carolina, similarly, created a psychiatry clinical informatics education track that was an application-based, 3-year, longitudinal experience with one resident spot available per year. Faculty mentors had 20% protected time and the educational track was focused on four pillars: service, education, research, and quality improvement.[15] Children's Hospital of Philadelphia has developed a three-pronged model that includes hands-on project experience, a longitudinal experience, and a clinical informatics resident working group.[14] As mentioned above, efforts in radiology and pathology residency have been more robust. Memorial Sloan Kettering, for instance, offers a 4-week rotation with its curriculum based on the Pathology Informatics Essentials for Residents curriculum and Training Residents in Genomics.[13] Both online curricula provide interactive modules and recorded lectures but also serve as helpful guides for content.[10] [17]

 

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Objectives

In 2017, at a large urban academic pediatric hospital, we deployed a clinical informatics curriculum with the goal of providing informatics education opportunities to all interested pediatric, pediatric neurology, and medicine-pediatric residents. We describe our experience with curriculum development and modification, implementation, and evaluation outcomes.

 

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Methods

Context

We are an academic pediatric integrated delivery network composed of primary care and specialty practices as well as a quaternary care 551-bed hospital located in San Diego. Our institution is the primary inpatient pediatric training site for categorical pediatric, pediatric neurology, and medicine–pediatric residents from our affiliated school of medicine and five other local training programs. We have a total of 76 residents across all years. In 2009, we transitioned from a paper-based health record to an EHR system (Epic, Epic Systems Corporation, Verona, Wisconsin, United States) that includes computerized provider order entry with clinical decision support.

 

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Curriculum Development

A resident clinical informatics rotation was conceptualized and created in 2017 by the Chief Medical Information Officer and one of the physician informaticists, a then senior pediatric resident (third postgraduate year). The elective initially focused on shadowing experiences and informatics project participation. The elective was not standardized, and resident awareness of the elective was minimal. In August 2020, the curriculum was standardized and redesigned to solidify informatics knowledge, promote longitudinal learning, and encourage real-world applications. Five physician informaticists comprise the faculty, all of whom participate in didactic teaching sessions, skill-building activities, and project mentorship. Two serve as the course directors. Both 2-week and 4-week elective blocks are offered throughout the year. Residents request the elective at the beginning of each academic year and are scheduled accordingly. Of the 26 2-week resident rotation blocks available, our elective is available across 22 blocks throughout the year. The total number of rotation blocks completed varies from year to year depending on residents' interest and their preassigned elective blocks. There is no application or selection process, but the rotation is limited to two to three residents per rotation block to optimize their experience. Each resident receives a customized rotation schedule and individual sessions with each faculty member. While the elective was initially in-person, with the redesign and the physical distancing guidelines imposed by the COVID-19 pandemic, all teaching sessions were converted to web conferencing platforms (e.g., Zoom, Microsoft Teams).

At the start of the rotation, residents meet with one of the course directors to assess the residents' knowledge and set goals for the rotation. Each resident is expected to identify either a clinical issue that could be addressed using informatics or an informatics component of an existing project to work on during the rotation. These small projects are varied with examples including gathering content for new order sets, developing criteria for best practice advisories, creating a steroid wean calendar, improving fertility preservation education for oncology patients, and architecting a patient-entered questionnaire. The resident is not expected to move a concept to production during the rotation but rather to learn how to approach a solution using informatics. To inform this work, the resident completes the Informatics Project Form with the course director (see [Appendix A1]) to identify their informatics area of interest and informatics mentor. Working with the course director to establish a rotation focus aims to help residents connect and apply informatics concepts learned to real-life examples. Additionally, this discussion empowers residents to identify ways in which informatics be used to improve efficiency, patient engagement, quality, and safety.

The 2-week elective employs self-study, skill-building, and didactic sessions along with informatics-related committee meeting attendance ([Table 1]). All didactics and skill-building activities are led by a physician informaticist. Residents may set up ad hoc meetings with faculty members for additional informatics project mentorship. Residents are encouraged to initiate their informatics project during the elective, applying newfound informatics knowledge to clinically relevant scenarios while having direct access to informatics resources. Some projects were able to be completed during the rotation; however, other projects continue to evolve after the elective and may take a year to complete. Residents may pursue Epic Power User classes or Physician Builder courses for additional skill training.

Table 1 Clinical informatics elective objectives and corresponding activities

Objective	Self-learning	Didactic	Skill-building
Introduction to clinical informatics
Compare and contrast information management, information systems, and informatics	Read: Chapter 1 Overview of Health Informatics by Hoyt
Describe the laws governing use of data, data sharing, and technical approaches to ensuring quality and protection of data	Review a chart for information pulled in from an outside health care organization via a health information exchange	• History of clinical and health informatics • HIPAA and 21st Century Cures • Patient privacy and security • Health information exchanges
Understand the importance of IT governance and change management.	• Review Rady's IT organizational chart • Read: steps to change by Kotter		• Complete Kotter's worksheet
EMR structure
Develop a theoretical and practical understanding of the role and structure of information in health care	Compare and contrast SNOMED and ICD 10 population during your SlicerDicer session	• ICD 10/SNOMED	• Learn how to create and personalize SmartPhrase, SmartList, and SmartLink.
Understand basic EMR terminology and data structure	• Watch Epic Builder Bites Videos:  SmartPhrases [MD502]  SmartLinks [MD503]  SmartLists [MD504]
Data literacy and structure
Understanding types of data and how EMR data are stored Describe the role of data across the health care system	• Reading: health care data analytics by Hoyt • Watch Epic builder bites videos: overview of Epic data structure [MD501]		• Epic SlicerDicer session/compare SNOMED and ICD 10 in SlicerDicer
Use the EMR to improve care and workflow
Define workflow and how it impacts quality, safety, and efficiency of care, Identify the range of clinical decision support tools; explain how to determine which application is appropriate for specific situations. Describe how to use EMR effectively and efficiently, Writing the perfect note in the EMR.	• Watch Epic video:   introduction to clinical decision support • Watch Larry Weed's 1971 Internal Medicine Grand Rounds • Analyze two standardized notes provided, apply our audit tool and see what you find. Clinical decision support [MD111]	• Clinical decision support	• Let's mix and match CDS • Attend clinical decision support meeting—monthly
Patient care engagement
Describe the OpenNotes project	• Review https://www.opennotes.org/ • Read: inviting patients to read their doctors' notes by Delbanco	• What is OpenNotes?	• Attend inpatient patient engagement group meeting—monthly

Abbreviation: EMR, electronic medical record.

Residents have the option to pursue a 4-week elective, offered as two distinct 2-week elective blocks at least 6 months apart. The goal of the 4-week elective is for in-depth learning and longitudinal informatics project completion. For the second 2-week block, residents are asked to choose one or more of the informatics tracks to focus their experience (Development and implementation of clinical decision support [CDS], Patient Care Engagement, EHR Data Extraction and Reporting, Provider Efficiency, Career Path in Informatics, see [Fig. 1]).

Fig. 1 Clinical informatics elective curriculum. Major informatics topics taught during the 2-week and 4-week clinical informatics elective.

 

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Self-Assessment and Elective Evaluation

Starting in 2020 with the elective redesign, residents were sent pre- and post-elective knowledge assessment and perception surveys. Knowledge assessment is a 9-question multiple choice quiz that tests residents' understanding of core class concepts such as health information exchange, CDS, patient engagement, and laws and regulations governing health privacy. The self-reported perception survey was an 8-item 5-point Likert scale evaluation (1: Strongly agree, 2: Somewhat agree, 3: Neutral, 4: Somewhat disagree, 5: Strongly disagree).[18] The perception survey assessed resident's understanding of informatics concepts (role of clinical informatics in clinical care, ways to efficiently utilize EHR, data structures, and information storage) and confidence (informatics knowledge application, self-service reporting tool utilization, EHR customization, and workflow analysis completion) in informatics tools and skill application. Residents also had the option to complete faculty teaching and elective rotation evaluations. The elective rotation evaluation assessed whether the rotation met its goals and objectives, whether it was a worthwhile experience, and whether the resident would recommend the elective to other residents. A free-text comment section was available for residents to further elaborate additional thoughts or suggestions. All assessments and surveys were distributed electronically via an evaluation software (MedHub, Minneapolis, Minnesota, United States).

 

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Statistical Analysis

Statistical analysis consisted of descriptive statistics using mean and standard deviation or counts/frequencies, where appropriate. Paired t-tests were used to analyze mean Likert scores for resident perception survey items. The Wilcoxon signed-rank test was used on residents' knowledge assessment score percentage.[19] Statistical significance was defined as a p-value of less than or equal to 0.05.

 

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Results

Residents and Their Projects

To date, 31 residents have completed the elective and the number of residents who completed the elective per year is noted in [Fig. 2]. The enrollment rate in 2017 was 1.56% and has increased to 12% in 2023. The enrollment rate is calculated as the percentage of all eligible residents who completed the elective. [Fig. 3] lists a sample of residents who completed the elective between 2017 and 2023 and the types of informatics projects completed. This highlights the breadth of projects residents participated in and the level of their project dissemination. Of the 31 residents, two pediatrics–neurology residents completed Epic physician builder certification with the funding support of the Neurology division.

Fig. 2 Number of residents enrolled in the elective. Number of residents who completed the clinical informatics elective each academic year from 2017 to 2023.

Fig. 3 Residents and their informatics projects. Sample of residents, their residency program, name of informatics project completed during or after clinical informatics elective, informatics project category, and presentation or publication after project completion between 2017 and 2023.

 

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Resident Perception Survey

Of the 20 residents who completed the elective between 2020 and 2023, 18 residents responded (90% response rate). There was a statistically significant decrease in the mean Likert scores ([Table 2]) when comparing pre- versus post-elective perception surveys across all domains covered during the rotation, indicating an overall improvement in the residents' understanding and confidence in the material presented. Residents reported having a better understanding of the role of clinical informatics in clinical care, increased understanding of how they can use the EHR more effectively and efficiently, improved understanding of data structures and information storage, increased confidence in their ability to apply informatics knowledge, increased comfort in utilizing self-service reporting tools, increased comfort in the ability to customize the medical record, and increased comfort in performing workflow analyses. As part of the rotation evaluation, residents have written that the strengths of the rotation included: “project flexibility that appeals to [resident's] interest,” “exposure to a wide variety of areas of hospital administration,” “teaching broadly applicable skills,” and “[faculty members] were approachable.” One area of improvement for the elective noted was “having [the elective offered] earlier in residency to better use the information learned.”

Table 2 Residents pre- and post-elective perception survey

Questions	Pre-elective (N = 18), mean (SD)	Post-elective (N = 18), mean (SD)	p-Value
	1: strongly agree to 5: strongly disagree
I understand the role of clinical informatics and clinical informaticist in clinical care	2.9 (1)	1.6 (1.1)	<0.001
I understand how to use EMR effectively and efficiently	2.4 (0.9)	1.8 (1)	0.03
I understand types of data and how they are stored in the EMR	3.6 (1)	1.7 (1.1)	<0.01
I am confident I can apply my knowledge of the EMR to improve workflow	2.7 (1)	1.6 (1.3)	0.03
I am comfortable using reporting/data generating tools (including SlicerDicer)	3.9 (1.1)	2 (0.9)	<0.01
I am comfortable customizing EMR tools for note writing (e.g., SmartPhrases, Macros, etc.)	2.6 (1.1)	1.5 (1.2)	0.004
I am comfortable critically assessing current workflows	3.4 (1.1)	1.9 (1.1)	0.001

Abbreviation: EMR, electronic medical record.

 

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Knowledge Assessment

Eighteen of 20 residents (90% response rate) completed pre-elective and post-elective 9-question knowledge assessments between 2020 and 2023. The knowledge assessment percentage score was calculated based on the percentage of questions answered correctly. Mean knowledge assessment percentage score increased from 77% (11.6) pre-elective to 92% (10.6) post-elective (p ≤ 0.05).

 

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Discussion

In this manuscript, we describe a well-received resident clinical informatics elective curriculum that focuses on knowledge foundation building, self-service reporting, EHR customization skill acquisition, and real-world application. Based on self-reported perception surveys, we were also successful at increasing residents' perceived understanding, self-efficacy, and confidence in utilizing clinical informatics concepts and EHR tools. Residents particularly enjoyed an overview of IT governance and structure through participation in multidisciplinary hospital committee meetings and exposure to physicians' administrative/leadership roles, which are rarely highlighted in clinical electives. Through this experiential portion of the rotation, residents also have interactions with multi-disciplinary operational leadership and clinical information system analysts. Additionally, the real-world application portion of the elective empowered residents to identify a current workflow problem and find solutions that would help them and their peers. The increasing number of residents enrolled in the elective each year demonstrates our success in increasing awareness and interest among trainees. Academic institutions should consider offering similar training opportunities to residents if one is not available.

Compared with other models published, our curriculum requires fewer funding resources and board-certified faculty members to support the resident elective.[12] [14] While our faculty are funded for operational informatics work, they do not receive funding for informatics teaching seen in other models.[12] [15] However, the standardized curriculum distributed among the five faculty members and project selection supporting operational initiatives reduces the burden on faculty mandates. We recognize that scaling up these educational initiatives may be difficult for institutions without robust resources. We also acknowledge that residents undergoing a 3-year residency training program, such as Pediatrics, might not have the flexibility to commit to multi-year informatics elective programs previously published.[15] [16] Additionally, while informatics education is important to all trainees in our current professional environment, we recognize that many residents strive to attain basic, practical informatics skills and knowledge without a goal to pursue a career in health informatics. Thus, compared with other models, ours was created to be easily accessible to residents, application-free, flexible, and not time-intensive so that the elective can be effortlessly incorporated into any resident's schedule. Our elective is also cost-neutral and does not impose on work-hour restrictions which has been previously reported in another model.[12]

Outcomes over the past 4 years have been encouraging. These successes rely on several key elements. First, the buy-in from residency leadership has been instrumental, not only providing the opportunity for the elective to grow but also giving the elective faculty members regular feedback on residents' informatics skill needs and knowledge gaps. Second, the residents' rotation evaluations have been helpful in the elective's continual improvements, allowing the rotation to cater to their needs. Lastly, the physician informaticists' dedication to teaching allowed us to sustain both the increasing number of elective participants and the long-term mentorship for trainees.

Given the pervasiveness of EHR usage and a rapidly advancing technological landscape in health care, it is now more important than ever for residents to be equipped with foundational knowledge and skills in informatics as they enter the workforce. Resident informatics engagement can accelerate the implementation of best practices and quality improvement through proficiency in data literacy, data acquisition, and clinical decision support tools. Additionally, with high rates of burnout often cited in medicine, improved EHR proficiency through informatics training may also promote efficiency, individual physician wellness, and job satisfaction.[20] We thus believe that informatics education, more than just the basic EHR orientation training, should be made available to all trainees. Our current model allows us to train up to approximately 66 residents per year in this elective, with a maximum of three residents per elective section, and we are able to accommodate every resident in our program. This may or may not be generalizable to other residency programs with more residents, which may require either a cap on participation or expanded faculty for the individualized portions of the elective. However, as our curriculum model is designed to be introductory with minimal resource requirements, we believe that it would be generalizable to other institutions with smaller or equivalent program sizes. Other programs may also need to adapt part of the curriculum to cover aspects that are unique to their organization's EHR platform.

While most of our trainee projects have addressed operational efficiencies thus far, one of the six domains of high-quality care identified by the Institute of Medicine, clinical informatics has the potential to address other essential aims for high-quality care, including patient safety, and effective and equitable care. Data to date suggest a role for clinical informatics tools (e.g., computerized physician order entry) for a reduction in medical errors and patient safety.[21] [22] Similarly, clinical informatics tools such as clinical decision support have been used to improve adherence to evidence-based guidelines and expert recommendations.[23] Finally, regarding equitable care, actively and repeatedly evaluating patient outcomes on a population level based on known disparity groupings (i.e., by ethnicity, socially and economically disadvantaged groups) can better define critical care disparities and gaps and also instigate, support, and evaluate needed interventions.[24] Future work will be needed to ascertain whether there is a persistence in knowledge and skills and whether utilization of such tools and/or data awareness translates into improved patient safety, reduced medical errors, improved performance of evidence-based guidelines, and more equitable care.

Due to the rapidly advancing nature of the field, flexibility is an inherent need in informatics curricula. Future elective content will continue to change with advancing EHR and health care technologies. This is what would make the elective most valuable to trainees. For example, we are adding more content on provider efficiency and proficiency as EHR software companies focus their efforts on creating individualized performance dashboards to display metrics to combat physician burnout.[25] We also incorporated more hands-on activities related to the patient portal (Epic MyChart, Epic Systems Corporation), EHR power user courses, informatics journal clubs, and clinical decision support improvements into the new curriculum. We also added a “train the trainer” experiential activity with elective participants serving as EHR trainers to their peers, a model that has been piloted successfully in the literature.[15]

 

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Conclusion

Clinical informatics education within a residency training program enriches the training experience and builds skills that can be applied throughout one's career. As seen by the growth of our program, there is a high demand among trainees for opportunities to learn and experience what clinical informatics is about. Although we have demonstrated that our curriculum has made a positive impact on our trainees, we aim to continue expanding our program, developing more training opportunities for all trainees, adapting the elective content to match real-world health care environments, and create graduates who are ready to work in the ever-changing landscape of health ITs.

 

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Clinical Relevance Statement

Aimed to teach pediatric residents foundational clinical informatics knowledge and applicable EHR skills, our clinical informatics curriculum demonstrated a positive impact on our trainees.

It is now more important than ever for trainees to be equipped with foundational informatics knowledge and skills before entering the workforce. The training content described in our manuscript could be adapted for use at other institutions and could contribute to future development of standardized, expanded clinical informatics training for trainees.

 

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Multiple Choice Questions

1. What was the initial focus of the resident clinical informatics elective before its standardization in August 2020?

   • Longitudinal learning and real-world applications.

   • In-depth learning and informatics tracks.

   • Shadowing experiences and informatics project participation.

   • Self-service reporting and clinical decision support.

   Correct Answer: The correct answer is option c. Shadowing experiences and informatics project participation. according to the manuscript, the initial focus of the resident clinical informatics elective before its standardization in August 2020 was on shadowing experiences and informatics project participation. The elective initially did not have a standardized curriculum, and residents engaged in shadowing experiences and participated in informatics projects. After the elective standardization, the focus was to solidify informatics knowledge, promote longitudinal learning, and encourage real-world applications.

2. What is a notable outcome of the clinical informatics elective between 2017 and 2023 reported in the manuscript?

   • A decrease in the enrollment rate.

   • Increased number of elective graduates pursued clinical informatics fellowship.

   • Increased resident understanding and confidence.

   • Funding decrease for the resident informatics elective program.

   Correct Answer: The correct answer is option c. Increased resident understanding and confidence. the manuscript reports that there was a statistically significant decrease in the mean Likert scores when comparing pre- versus post-surveys across all domains covered during the rotation. The domains covered during the rotation included the role of clinical informatics in clinical care, effective and efficient use of the EHR, understanding of data structures and information storage, application of informatics knowledge, utilization of self-service reporting tools, customization of the medical record, and performance of workflow analyses. The decrease in Likert scores indicates an overall improvement in residents' understanding and confidence in these domains, suggesting a positive impact of the clinical informatics elective on the residents' experience and skills. There was an increase in enrollment rate, thus option a is incorrect. Options b and d were not outcomes of the study described.

 

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Conflict of Interest

None declared.

Protection of Human and Animal Subjects

The study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects, and was reviewed by the local institutional review board.

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Publikationsverlauf

Eingereicht: 21. Januar 2024

Angenommen: 12. April 2024

Artikel online veröffentlicht:
05. Juni 2024