Toward a Learning Health Care System: A Systematic Review and Evidence-Based Conceptual Framework for Implementation of Clinical Analytics in a Digital Hospital

Objective  A learning health care system (LHS) uses routinely collected data to continuously monitor and improve health care outcomes. Little is reported on the challenges and methods used to implement the analytics underpinning an LHS. Our aim was to systematically review the literature for reports of real-time clinical analytics implementation in digital hospitals and to use these findings to synthesize a conceptual framework for LHS implementation. Methods  Embase, PubMed, and Web of Science databases were searched for clinical analytics derived from electronic health records in adult inpatient and emergency department settings between 2015 and 2021. Evidence was coded from the final study selection that related to (1) dashboard implementation challenges, (2) methods to overcome implementation challenges, and (3) dashboard assessment and impact. The evidences obtained, together with evidence extracted from relevant prior reviews, were mapped to an existing digital health transformation model to derive a conceptual framework for LHS analytics implementation. Results  A total of 238 candidate articles were reviewed and 14 met inclusion criteria. From the selected studies, we extracted 37 implementation challenges and 64 methods employed to overcome such challenges. We identified common approaches for evaluating the implementation of clinical dashboards. Six studies assessed clinical process outcomes and only four studies evaluated patient health outcomes. A conceptual framework for implementing the analytics of an LHS was developed. Conclusion  Health care organizations face diverse challenges when trying to implement real-time data analytics. These challenges have shifted over the past decade. While prior reviews identified fundamental information problems, such as data size and complexity, our review uncovered more postpilot challenges, such as supporting diverse users, workflows, and user-interface screens. Our review identified practical methods to overcome these challenges which have been incorporated into a conceptual framework. It is hoped this framework will support health care organizations deploying near-real-time clinical dashboards and progress toward an LHS.     

Arthrogryposis multiplex congenita of the temporomandibular joint

A case of arthrogryposis multiplex congenita involving the temporomandibular joint is reported. This is only the second reported case in which surgery was used in an attempt to alleviate the limited mandibular opening that may be associated with this uncommon condition. The clinical findings at the time of surgery differed significantly from those classically associated with other joints afflicted with this condition, suggesting that a different pathophysiologic mechanism may be involved.     

Anesthesia Technique and Outcomes of Endovascular Aneurysm Repair

Anesthetic techniques vary widely in the endovascular repair of abdominal aortic aneurysms (EVAR). Previous studies have demonstrated the feasibility of using local anesthesia. However, the ideal anesthetic technique has not been determined. This study examines whether anesthesic technique influences the outcomes of EVAR. Data regarding demographics, risk factors, procedural characteristics, recovery characteristics, treatment complications, acute (<30 day) medical complications, mortality, and anesthetic type were prospectively collected during the AneuRx phase II aortic endograft trial. Patient cohorts receiving general, regional, or local anesthesia were compared. From 1997 to 1998, 424 patients underwent EVAR at 13 sites using the AneuRx Bifurcated endograft. There were 279 patients in the general anesthesia group, 95 patients in the regional group, and 50 patients in the local group. Risk factors were similar. There were no significant differences in age, gender, American Society of Anesthesiologists grade, length of anesthesia, branch artery occlusions, proximal endoleaks, failed implants, or open surgical conversions. Cardiac, renal, and wound-healing complications were all lower in the local group. Mortality was equivalent among the three groups. (p > 0.05, ANOVA). From these results we concluded that EVAR with local anesthesia is a safe and efficacious method that may reduce recovery times and postoperative medical morbidity compared to use of genera1 or spinal/epidural anesthesia.     

Genetic linkage analysis in hereditary non-polyposis colon cancer syndrome.

Hereditary Non-polyposis Colon Cancer Syndrome (HNPCC) is the most common cause of familial colorectal cancer. Molecular genetic studies of HNPCC have shown evidence of locus heterogeneity, and mutations in four genes (hMSH2, hMLH1, hPMS1, and hPMS2) which encode components of the mismatch enzyme repair system may cause HNPCC. To determine the extent and nature of locus heterogeneity in HNPCC, we performed genetic linkage studies in 14 HNPCC families from eastern and north-western England. Linkage to hMLH1 was excluded in six families, each of which were likely to be linked to hMSH2 (lod score > 1.0 in each family and total lod score for all six families = 7.64). Linkage to hMSH2 was excluded in three families, each of which were likely to be linked to hMLH1 (lod score > 1.0 in each family and total lod score at hMLH1 for all three families = 3.93). In the remaining five families linkage to hMSH2 or hMLH1 could not be excluded. These results confirm locus heterogeneity in HNPCC and suggest that, in the population studied, most large families with HNPCC will have mutations in hMSH2 or hMLH1. We did not detect any correlation between clinical phenotype and the genetic linkage results, but a Muir-Torre syndrome family excluded from linkage to hMLH1 was likely to be linked to hMSH2 and showed microsatellite instability in a tumour from an affected relative.     

Bone formation rate in older normal women: concurrent assessment with bone histomorphometry, calcium kinetics, and biochemical markers

In 12 younger (age, 30-41 yr) and 11 older (age, 55-73 yr) normal women we assessed bone formation rate using multiple methods. Bone formation (mean +/- SE) was higher in the older women than in the younger women, based on measurements of serum bone Gla-protein (1.67 +/- 0.07 vs. 1.14 +/- 0.10 nmol/L; P less than 0.01), serum bone-specific alkaline phosphatase activity (388 +/- 42 vs. 223 +/- 22 nanokatal/L, P less than 0.01), and bone formation rate by histomorphometry of iliac biopsy (31.1 +/- 4.9% vs. 15.1 +/- 2.7%/yr; P less than 0.01), but was similar in the two groups when accretion rates were assessed by calcium kinetics (5.9 +/- 1.0 vs. 7.5 +/- 1.2; P = NS). This latter discrepancy may have been caused by several age-related factors, especially reduced mineralization of completed osteons, and by not correcting for the decrease in total skeletal calcium in the older group. Our data call into question the traditional belief that bone turnover decreases in older women.     

Automated Sequence Preprocessing in a Large-Scale Sequencing Environment

A software system for transforming fragments from four-color fluorescence-based gel electrophoresis experiments into assembled sequence is described. It has been developed for large-scale processing of all trace data, including shotgun and finishing reads, regardless of clone origin. Design considerations are discussed in detail, as are programming implementation and graphic tools. The importance of input validation, record tracking, and use of base quality values is emphasized. Several quality analysis metrics are proposed and applied to sample results from recently sequenced clones. Such quantities prove to be a valuable aid in evaluating modifications of sequencing protocol. The system is in full production use at both the Genome Sequencing Center and the Sanger Centre, for which combined weekly production is ~100,000 sequencing reads per week.     

X-ray absorption spectroscopy using synchrotron radiation for structural investigation of organometallic molecules of biological interest.

The technique of x-ray absorption spectroscopy using tuneable, very intense x-rays from a high energy electron storage ring has been applied to study of the estended x-ray absorption fine structure for Cu and Ni tetraphenylporphyrin and methemoglobin. Preliminary analysis shows that the spectra may be interpreted as a super-position of modulations arising from the nearest neighbor nitrogen and pyrrole alpha-carbon coordination sheels of the metal atoms. We estimate that with the observed magnitude of noise to modulation amplitude, relative shifts of 0,5% in the metal-nitrogen to metal-carbon bond distances in the prophyrins should be observable using extended x-ray absorption fine structure and that this technique may provide a method of observing these types of structural changes in solution.     

Selective IgA deficiency and Crohn's disease: report of two cases.

Two patients are described with Crohn's disease and selective IgA deficiency. Serum IgA was undetectable in each case, and immunoperoxidase studies of the lamina propria showed a gross diminution of IgA-bearing plasma cells. Peripheral blood lymphocytes, however, showed normal numbers of IgA-bearing lymphocytes. The typical clinical course and histology in these two patients suggest that IgA-mediated responses in the mucosa are not involved in the pathogenesis of Crohn's disease.