The evolution of medical informatics in China: A retrospective study and lessons learned

BackgroundIn contrast to China’s giant health information technology (HIT) market and tremendous investments in hospital information systems the contributions of Chinese scholars in medical informatics to the global community are very limited. China would like to have a more important position in the global medical informatics community.ObjectiveA better understanding of the differences between medical informatics research and education in China and the discipline that emerged abroad will better inform Chinese scholars to develop right strategies to advance the field in China and help identify an appropriate means to collaborate more closely with medical informatics scholars globally.MethodFor the first time, this paper divides the evolution of medical informatics in China into four stages based on changes in the core content of research, the educational orientation and other developmental characteristics. The four stages are infancy, incubation, primary establishment and formal establishment. This paper summarizes and reviews major supporting journals and publications, as well as major organizations. Finally, we analyze the main problems that exist in the current disciplinary development in China related to medical informatics research and education and offer suggestions for future improvement.ConclusionsThe evolution of medical informatics shows a strong and traditional concentration on medical library/bibliographic information rather than medical (hospital information or patient information) information. Misdirected-concentration, a lack of formal medical informatics trained teaching staff and mistakenly positioning medical informatics as an undergraduate discipline are some of the problems inhibiting the development of medical informatics in China. These lessons should be shared and learned for the global community.     

Delivery of pediatric sleep services via telehealth: the Alberta experience and lessons learned

Concerns regarding a child's sleep, identified by a caregiver or by the health care practitioner, are commonly raised but often left unexplored. Families in geographically isolated areas, with limited access to specialty services such as pediatric sleep medicine, are at increased risk for unmet treatment needs. Telehealth is a potential vehicle for delivery of these specialty services and overcoming barriers in diagnosing and treating sleep disorders in children by improving access and enhancing support for the families in their communities. This article describes the initiation of a pilot program in the delivery of multidisciplinary pediatric sleep medicine services via telehealth in Alberta, Canada.     

The use of think-aloud and instant data analysis in evaluation research: Exemplar and lessons learned

While health information technologies have become increasingly popular, many have not been formally tested to ascertain their usability. Traditional rigorous methods take significant amounts of time and manpower to evaluate the usability of a system. In this paper, we evaluate the use of instant data analysis (IDA) as developed by Kjeldskov et al. to perform usability testing on a tool designed for older adults and caregivers. The IDA method is attractive because it takes significantly less time and manpower than the traditional usability testing methods. In this paper we demonstrate how IDA was used to evaluate usability of a multifunctional wellness tool, discuss study results and lessons learned while using this method. We also present findings from an extension of the method which allows the grouping of similar usability problems in an efficient manner. We found that the IDA method is a quick, relatively easy approach to identifying and ranking usability issues among health information technologies.     

Usability study of clinical exome analysis software: Top lessons learned and recommendations

ObjectivesNew DNA sequencing technologies have revolutionized the search for genetic disruptions. Targeted sequencing of all protein coding regions of the genome, called exome analysis, is actively used in research-oriented genetics clinics, with the transition to exomes as a standard procedure underway. This transition is challenging; identification of potentially causal mutation(s) amongst ∼10⁶ variants requires specialized computation in combination with expert assessment. This study analyzes the usability of user interfaces for clinical exome analysis software. There are two study objectives: (1) To ascertain the key features of successful user interfaces for clinical exome analysis software based on the perspective of expert clinical geneticists, (2) To assess user-system interactions in order to reveal strengths and weaknesses of existing software, inform future design, and accelerate the clinical uptake of exome analysis.MethodsSurveys, interviews, and cognitive task analysis were performed for the assessment of two next-generation exome sequence analysis software packages. The subjects included ten clinical geneticists who interacted with the software packages using the “think aloud” method. Subjects’ interactions with the software were recorded in their clinical office within an urban research and teaching hospital. All major user interface events (from the user interactions with the packages) were time-stamped and annotated with coding categories to identify usability issues in order to characterize desired features and deficiencies in the user experience.ResultsWe detected 193 usability issues, the majority of which concern interface layout and navigation, and the resolution of reports. Our study highlights gaps in specific software features typical within exome analysis. The clinicians perform best when the flow of the system is structured into well-defined yet customizable layers for incorporation within the clinical workflow. The results highlight opportunities to dramatically accelerate clinician analysis and interpretation of patient genomic data.ConclusionWe present the first application of usability methods to evaluate software interfaces in the context of exome analysis. Our results highlight how the study of user responses can lead to identification of usability issues and challenges and reveal software reengineering opportunities for improving clinical next-generation sequencing analysis. While the evaluation focused on two distinctive software tools, the results are general and should inform active and future software development for genome analysis software. As large-scale genome analysis becomes increasingly common in healthcare, it is critical that efficient and effective software interfaces are provided to accelerate clinical adoption of the technology. Implications for improved design of such applications are discussed.     

A2A receptors in inflammation and injury: lessons learned from transgenic animals

Adenosine regulates the function of the innate and adaptive immune systems through targeting virtually every cell type that is involved in orchestrating an immune/inflammatory response. Of the four adenosine receptors (A(1), A(2A), A(2B), A(3)), A(2A) receptors have taken center stage as the primary anti-inflammatory effectors of extracellular adenosine. This broad, anti-inflammatory effect of A(2A) receptor activation is a result of the predominant expression of A(2A) receptors on monocytes/macrophages, dendritic cells, mast cells, neutrophils, endothelial cells, eosinophils, epithelial cells, as well as lymphocytes, NK cells, and NKT cells. A(2A) receptor activation inhibits early and late events occurring during an immune response, which include antigen presentation, costimulation, immune cell trafficking, immune cell proliferation, proinflammatory cytokine production, and cytotoxicity. In addition to limiting inflammation, A(2A) receptors participate in tissue remodeling and reparation. Consistent with their multifaceted, immunoregulatory action on immune cells, A(2A) receptors have been shown to impact the course of a wide spectrum of ischemic, autoimmune, infectious, and allergic diseases. Here, we review the regulatory roles of A(2A) receptors in immune/inflammatory diseases of various organs, including heart, lung, gut, liver, kidney, joints, and brain, as well as the role of A(2A) receptors in regulating multiple organ failure and sepsis.     

HIV vaccine research in Thailand: lessons learned

Thailand is the only country that has conducted two Phase III efficacy trials and ten other Phase I/II studies using various HIV-1 vaccine constructs. This outstanding record is the result of strong efforts and commitment among various partners, including policy makers, regulators, researchers and foreign collaborators. Recently, it has become apparent that hardly any new HIV/AIDS candidate vaccines are in the pipeline reaching the stage of clinical testing, especially a candidate vaccine that is suitable for Thailand and the surrounding region. However, many lessons learned can be utilized or modified for other vaccine trials, particularly vaccines against other infectious diseases prevalent in developing countries.     

A typical case of myoclonic epilepsy with ragged red fibers (MERRF) and the lessons learned

Mitochondrial diseases have a special predilection to involve the brain in view of its high metabolic demand and the tendency for the formation of excitatory neurotransmitters when there is deficiency of intracellular ATP. These diseases have a great phenotypic variation and need a high degree of suspicion. However, some specific syndromes are well defined, both genotypically and phenotypically. Some of the drugs are potentially fatal mitochondrial poisons and an insight into that may be lifesaving as well as prevent serious morbidities. We report a typical case of myoclonic epilepsy with ragged red fibers (MERRF) with classical phenotype and genotype. There was rapid multiaxial deterioration with the introduction of sodium valproate which partly reversed on introducing mitochondrial cocktail and withdrawal of the offending drug. Sodium valproate, phenobarbitone, chloramphenicol and many anti-viral agents are mitochondrial poisons that increase the morbidity and mortality in patients with mitochondrial disease. More harm to the patient can be avoided with insight into this information.KEY WORDS: Midline lipoma, mitochondrial disease, sodium valproate     

T cell-directed therapies: lessons learned and future prospects

Agents interfering with T cell function are therapeutic mainstays for various autoimmune diseases and for transplant approaches to organ failure. The understanding of T cell biology has blossomed since the development of most agents now in use. Here we discuss T cell-specific agents now in use, others recently added to the therapeutic armamentarium and promising agents being investigated in clinical and preclinical studies. In addition, we reflect on the risks and benefits involved in the testing of such agents clinically, with examples of agents that have successfully been used in the clinic and agents that failed to reach therapeutic use.     

A structural voyage toward an understanding of the MHC-I-restricted immune response: lessons learned and much to be learned

T cells that express clonally distributed αβ T-cell receptors (TCRs) corecognize antigenic peptides (p) bound to major histocompatibility complex class I (MHC-I) and class II molecules (MHC-II). Extensive human leukocyte antigen (HLA) polymorphism enables HLA molecules from different haplotypes to capture an array of self- and microbe-derived peptide antigens that is fundamental to adaptive immunity. T cells developing in the thymus are selected for weak binding to self-peptide-HLA complexes generating a vast repertoire of clonally distinct T cells in the periphery. Indeed, diversity within germline loci and the finally assembled TCR genes, coupled with inherent TCR cross-reactivity, enables CD8⁺ T cells to survey the multitude of pHLA-I landscapes. Precisely how does the TCR ligate to pHLA-I, and how does knowledge of the detailed structural interactions inform immunobiology? A recent number of our structural studies concerning the TCR-pMHC-I axis, alongside others in the field, have provided insight into HLA-I polymorphism, pMHC-I flexibility, TCR bias, TCR polymorphism, maintenance of self-tolerance, T-cell cross-reactivity, and alloreactivity. Collectively, the data also provide an opportunity to address the structural correlates of MHC-I restriction. Here, we provide our perspective concerning these advances in the field. Although much key information has been gleaned, the structural data show that some of the key concepts surrounding the TCR-pMHC-I interaction remain controversial and unresolved.     

Rotavirus vaccine introduction in the Americas: progress and lessons learned

In Latin America and the Caribbean, rotavirus causes approximately 15,000 deaths, 75,000 hospitalizations, 2 million clinic visits and 10 million cases of rotavirus diarrhea annually. Two safe vaccines are available that are effective in preventing severe illness. To date, seven countries in Latin America (Brazil, Ecuador, El Salvador, Panama, Mexico, Nicaragua and Venezuela) have introduced the vaccine. For successful rotavirus vaccine introduction, the lessons learned re-emphasize the critical need for countries to have precise plans that will ensure technical, programmatic and financial sustainability of vaccine introduction. Of these lessons learned, programmatic feasibility and financial sustainability were particularly challenging for countries that were the first to introduce a rotavirus vaccine.     

Cytokine reporter mice in immunological research: perspectives and lessons learned

Cytokines are soluble messenger molecules with important regulatory functions throughout the immune system. 'Cytokine reporter' strains express marker molecules under control of elements from cytokine genes allowing for easy identification of their cellular sources. Such systems are well-accepted tools for research of cytokine function. The value of these strains lies in the ability to perform experiments relying on identification and isolation of live cytokine-expressing cells, provided that the reporter faithfully reflects the proper cytokine mRNA and protein production. As more diverse cell subsets are defined by their cytokine expression, the field has adapted with the generation of more sophisticated strains. In this review we summarize the evolution of cytokine detection methods and give examples of knowledge gained using cytokine reporter mice for cell types expressing interferon-γ and interleukin-4, -10 and -17. We also discuss current options for generating such reporter strains and their potential pitfalls.     

Estrogen and cognitive functioning in women: lessons we have learned

Extant research findings allow several conclusions regarding the relationship between estrogen and cognitive functioning across the female life span. First, performance on tests of verbal memory fluctuates in concert with physiological changes in ovarian hormone production during the menstrual cycle and during pregnancy and the postpartum period. Estrogen therapy (ET) prevents the decrease in verbal memory when administered immediately following the surgical removal of both ovaries in premenopausal women. Some, but relatively little evidence is available to support the idea that ET, initiated at the time of a natural or a surgical menopause for a few years, may protect against cognitive decline 30 years later and more research in this area is urgently needed. Finally, the evidence to date strongly suggests that the initiation of ET decades after the menopause has occurred does not protect against cognitive decline or dementia. Taken together, these findings support the so-called "window of opportunity" hypothesis which holds that ET will be neuroprotective only when administered closely in time to a natural or surgical menopause.     

Molecular pathogenesis of lymphangioleiomyomatosis: lessons learned from orphans

Lymphangioleiomyomatosis (LAM) is a rare progressive cystic lung disease affecting young women. The pivotal observation that LAM occurs both spontaneously and as part of the tuberous sclerosis complex (TSC) led to the hypothesis that these disorders share common genetic and pathogenetic mechanisms. In this review we describe the evolution of our understanding of the molecular and cellular basis of LAM and TSC, beginning with the discovery of the TSC1 and TSC2 genes and the demonstration of their involvement in sporadic (non-TSC) LAM. This was followed by rapid delineation of the signaling pathways in Drosophila melanogaster with confirmation in mice and humans. This knowledge served as the foundation for novel therapeutic approaches that are currently being used in human clinical trials.     

Towards the measurement of event-related EEG activity in real-life working environments

In applied contexts, psychophysiological measures have a long tradition to evaluate the user state. EEG correlates that indicate mechanisms of information processing, however, are hardly accessible since discrete time stamps that are necessary for this approach are commonly not available in natural situations. However, eye blinks may close this gap. Eye blinks are assumed to mark distinct points in information processing, necessary to segment the incoming data stream. By using mobile EEG in a simulated working situation we demonstrate that eye-blink-related potentials provide reliable information about cognitive processing in distinct working environments. During cognitive tasks, an increase in the fronto-central N2 component as well as evoked theta activity can be shown, both indices of enhanced cognitive control. The posterior P3 is reduced during physical tasks (sorting of boxes), probably reflecting the more continuous nature of this task. The data are discussed within a model of dopaminergic modulation of blink activity that involves both task specific aspects like executive control and modulating influences of motivation or fatigue.     

Platelets and psychiatry: lessons learned from old and new studies

Platelets play an important role not only in hemostasis but also in the pathophysiology of coronary artery disease. The complex interactions among the vascular endothelium, platelets, and blood components are one of the most exciting research areas today. This review addresses some fundamentals of platelet physiology and examines why platelets are interesting probes for neurophysiology. Results of current studies suggest that platelets are affected by diverse stressors, including psychological ones, and that platelets offer an interesting vantage point for understanding the neurophysiology of various psychiatric disorders. We also describe how platelets have been used for various types of research, including studies of stress associated with cardiovascular disease and studies of platelets in psychopharmacological research. Finally, we examine some of the psychiatric literature related to platelets; these studies range from case studies from the 1920s to contemporary experimental studies.     

Video observation in HIT development: lessons learned on benefits and challenges

ABSTRACT: BACKGROUND: Experience shows that the precondition for the development of successful health information technologies is a thorough insight into clinical work practice. In contemporary clinical work practice, clinical work and health information technology are integrated, and part of the practice is tacit. When work practice becomes routine, it slips to the background of the conscious awareness and becomes difficult to recognize without the context to support recall. This means that it is difficult to capture with traditional ethnographic research methods or in usability laboratories or clinical set ups. Observation by the use of the video technique within healthcare settings has proven to be capable of providing a thorough insight into the complex clinical work practice and its context - including parts of the tacit practice. The objective of this paper is 1) to argue for the video observation technique to inform and improve health-information-technology development and 2) to share insights and lessons learned on benefits and challenges when using the video observation technique within healthcare settings. METHODS: A multiple case study including nine case studies conducted by DaCHI researchers 2004[EN DASH]2011 using audio-visual, non-participant video observation for data collection within different healthcare settings. RESULTS: In HIT development, video observation is beneficial for 1) informing and improving system design 2) studying changes in work practice 3) identifying new potentials and 4) documenting current work practices. CONCLUSIONS: The video observation technique used within healthcare settings is superior to other ethnographic research methods when it comes to disclosing the complexity in clinical work practice. The insights gained are far more realistic compared to traditional ethnographic studies or usability studies and studies in clinical set ups. Besides, the data generated through video recordings provide a solid basis for dialog between the health care professionals involved. The most important lessons learned are that a well considered methodology and clear formulated objectives are imperative, in order to stay focused during the data rich analysis phase. Additionally, the video observation technique is primarily recommended for studies of specific clinical work practices within delimited clinical settings. Overall, the video observation technique has proven to be capable of improving our understanding of the interwoven relation between clinical work practice and HIT and to inform us about user requirements and needs for HIT, which is a precondition for the development of more successful HIT systems in the future.     

Medicare competitive pricing: lessons learned in Phoenix and Kansas City.

Many lawmakers have embraced the idea of bringing more competition to the Medicare program as a way to achieve greater cost efficiency and provide more choice for beneficiaries. Advocates of this strategy believe Medicare should move away from its historical administrative pricing approach toward a competitive bidding process similar to those used by many private purchasers. Yet, despite support for the concept, every effort to test it in the marketplace has been met with strong opposition. Most recently, competitive bidding demonstration projects set to take place in Phoenix and Kansas City have been delayed by congressional action. Nevertheless, it is clear that those participating in the demonstration projects-notably private purchasers, consumers, health plans, and the Health Care Financing Administration-have already learned a great deal about the types of issues that must be considered if Medicare is truly to pay health plans in a competitive manner. This article explores the lessons learned so far in Phoenix and Kansas City, including design considerations such as plan participation, the standard benefit package, the bidding process, and the government contribution to premiums. It also examines the reasons for opposition to the project and their implications for broader Medicare reform efforts.