A global socio-economic-medico-legal model for the sustainability of longitudinal electronic health records - part 2.

OBJECTIVES: This paper pursues the challenge of sustaining lifetime electronic health records (EHRs) based on a comprehensive socio-economic-medico-legal model. The notion of a lifetime EHR extends the emerging concept of a longitudinal and cross-institutional EHR and is invaluable information for increasing patient safety and quality of care. METHODS: The challenge is how to compile and sustain a coherent EHR across the lifetime of an individual. Several existing and hypothetical models are described, analyzed and compared in an attempt to suggest a preferred approach. RESULTS: The vision is that lifetime EHRs should be sustained by new players in the healthcare arena, who will function as independent health record banks (IHRBs). Multiple competing IHRBs would be established and regulated following preemptive legislation. They should be neither owned by healthcare providers nor by health insurer/payers or government agencies. The new legislation should also stipulate that the records located in these banks be considered the medico-legal copies of an individual's records, and that healthcare providers no longer serve as the legal record keepers. CONCLUSIONS: The proposed model is not centered on any of the current players in the field; instead, it is focussed on the objective service of sustaining individual EHRs, much like financial banks maintain and manage financial assets. This revolutionary structure provides two main benefits: 1) Healthcare organizations will be able to cut the costs of long-term record keeping, and 2) healthcare providers will be able to provide better care based on the availability of a lifelong EHR of their new patients.

A global socio-economic-medico-legal model for the sustainability of longitudinal electronic health records. Part 1.

OBJECTIVES: This paper pursues the challenge of sustaining lifetime electronic health records (EHRs) based on a comprehensive socio-economic-medico-legal model. The notion of a lifetime EHR extends the emerging concept of a longitudinal and cross-institutional EHR and is invaluable information for increasing patient safety and quality of care. METHODS: The challenge is how to compile and sustain a coherent EHR across the lifetime of an individual. Several existing and hypothetical models are described, analyzed and compared in an attempt to suggest a preferred approach. RESULTS: The vision is that lifetime EHRs should be sustained by new players in the healthcare arena, who will function as independent health record banks (IHRBs). Multiple competing IHRBs would be established and regulated following preemptive legislation. They should be neither owned by healthcare providers nor by health insurer/payers or government agencies. The new legislation should also stipulate that the records located in these banks be considered the medico-legal copies of an individual's records, and that healthcare providers no longer serve as the legal record keepers. CONCLUSIONS: The proposed model is not centered on any of the current players in the field; instead, it is focussed on the objective service of sustaining individual EHRs, much like financial banks maintain and manage financial assets. This revolutionary structure provides two main benefits: 1) Healthcare organizations will be able to cut the costs of long-term record keeping, and 2) healthcare providers will be able to provide better care based on the availability of a lifelong EHR of their new patients.

Experimental immunogenic rubeosis iridis.

We have developed a primate model of rubeosis iridis in monkeys systemically sensitized to crystalline beef insulin. After intravitreal insulin injection, the dose-related immunogenic inflammation includes cells, flare, fibrin, and blood in the anterior chamber. With more severe inflammation, posterior synechiae, iris bombé, and cataracts occur. Of particular importance, new blood vessels develop within the stroma and on the anterior surface of the iris. Following injection of small amounts of insulin, the anterior surface vessels may regress over time, and the iris regains its normal appearance and coloration. However, the new stromal vessels persist and are cuffed by inflammatory cells including plasma cells. After injection of large amounts of insulin, more extensive structural alterations develop as noted above in conjunction with persistent iris anterior surface and stromal neovascularization. The relationship of rubeosis iridis to clinical inflammatory syndromes and to previous laboratory studies is discussed. Stromal neovascularization was a consistent finding in this experimental model even when anterior surface vessels regressed. On the basis of these experimental data and a review of publications describing human pathology, we believe that a broadening of the classic definition of rubeosis iridis is waranted to include a recognition of the stromal component of the clinical and pathologic findings.

Experimental immunogenic proliferative retinopathy in monkeys.

When a small amount of bovine serum albumin (BSA) was injected into the posterior vitreous body of a sensitized monkey, an immunogenic response occurred in the major blood vessels of the optic disk. In nonsensitized monkeys, the same phenomenon appeared after repeated intravitreal injections of small amounts of BSA. Focal leaks of fluorescein from the optic disk vessels were demonstrated by fluorescein angiography. Correlative light and electron microscopy revealed infiltration of acute and chronic inflammatory cells from the vessels of the optic disk into the vitreous body. When larger amounts of BSA were injected in sensitized monkeys, in addition to optic nerve involvement, there were scattered retinal vascular hemorrhagic and exudative lesions throughout the posterior pole. Immunologic mechanisms can result in preferential optic disk involvement with formation of proliferative lesions during the healing phase of the immunogenic inflammation.

Structural alterations in the ciliary process and the blood-aqueous barrier of the monkey after systemic urea injections.

The structural alterations induced in the monkey ciliary epithelium by intravascular injection of urea solutions were studied with the light and electron microscopes. Arterial injection of urea resulted in destruction of the nonpigmented epithelium and the consequent breakdown of the blood-aqueous barrier. The intravenous injection did not significantly affect the structural integrity of the ciliary epithelium. The intercellular zonulae occludens were not altered and the intercellular pathway from blood to posterior chamber remained closed to horseradish peroxidase. Intercellular uptake in large cytoplasmic vacuoles appeared to account for some late transport to the basal end of the nonpigmented epithelium. There was no comparable transport of peroxidase in vesicles or vacuoles through the nonpigmented epithelium in animals not subjected to intravenous urea treatment. Compared to the arterial route, intravenous administration of urea does not appear to pose a serious threat to the integrity of the ciliary epithelium.

Rubeosis iridis generated by insulin hypersensitivity.

There are important similarities between human and experimental monkey rubeosis iridis. We believe that we have developed a useful primate model to study iris neovascularization and that the possible role of immunity to insulin in the pathogenesis of human diabetic rubeosis iridis warrants further detailed consideration.

It's time for health record banking!

This article is part of a Focus Theme of Methods of Information in Medicine on Health Record Banking. This Focus Theme aims at describing the Health Record Banking (HRB) paradigm, which offers an alternative constellation of health information exchange and integration through sustainability of health records over the lifetime of individuals by independent and trusted organizations. It also aims at describing various approaches to HRB and reporting on the state-of-the-art HRB through actual implementations and lessons learned, as described in articles of this Focus Theme.

Future Direction of IMIA Standardization. Report from the IMIA Standardization Working Group.

OBJECTIVES: Standardization in the field of health informatics has increased its importance and global alliance for establishing interoperability and compatibility internationally. Standardization has been organized by standard development organizations (SDOs) such as ISO (International Organization for Standardization), CEN (European Committee for Standardization), IHE (Integrating the Healthcare Enterprise), and HL7 (Health Level 7), etc. This paper reports the status of these SDOs' activities. METHODS: In this workshop, we reviewed the past activities and the current situation of standardization in health care informatics with the standard development organizations such as ISO, CEN, IHE, and HL7. Then we discussed the future direction of standardization in health informatics toward "future medicine" based on standardized technologies. RESULTS: We could share the status of each SDO through exchange of opinions in the workshop. Some WHO members joined our discussion to support this constructive activity. CONCLUSION: At this meeting, the workshop speakers have been appointed as new members of the IMIA working groups of Standards in Health Care Informatics (WG16). We could reach to the conclusion that we collaborate for the international standardization in health informatics toward "future medicine".

IBM's Health Analytics and Clinical Decision Support.

OBJECTIVES: This survey explores the role of big data and health analytics developed by IBM in supporting the transformation of healthcare by augmenting evidence-based decision-making. METHODS: Some problems in healthcare and strategies for change are described. It is argued that change requires better decisions, which, in turn, require better use of the many kinds of healthcare information. Analytic resources that address each of the information challenges are described. Examples of the role of each of the resources are given. RESULTS: There are powerful analytic tools that utilize the various kinds of big data in healthcare to help clinicians make more personalized, evidenced-based decisions. Such resources can extract relevant information and provide insights that clinicians can use to make evidence-supported decisions. There are early suggestions that these resources have clinical value. As with all analytic tools, they are limited by the amount and quality of data. CONCLUSION: Big data is an inevitable part of the future of healthcare. There is a compelling need to manage and use big data to make better decisions to support the transformation of healthcare to the personalized, evidence-supported model of the future. Cognitive computing resources are necessary to manage the challenges in employing big data in healthcare. Such tools have been and are being developed. The analytic resources, themselves, do not drive, but support healthcare transformation.

Effect of prostaglandin on the blood aqueous barrier in the rabbit ciliary process.

Distinct structural changes occur in the rabbit ciliary epithelium following intravitreal injection of prostaglandin E-1 (PGE-1). Up to four hours after PGE-1 administration, alteration of the pigmented epithelium was characterized by dilated intercellular spaces and the disruption of many intercellular junctions. The nonpigmented epithelium demonstrates a spectrum of morphologic variation from only some thinning of cytoplasmic processes to area of severe distortion. In these regions, marked thinning of the nonpigmented cells occurs in association with an absence of apical tight junctions. This alteration of the nonpigmented epithelium and its tight junctions allows for the leakage of proteins into the posterior chamber which is consistent with the breakdown in the blood-aqueous barrier. The temporal sequence of these changes would suggest a differential susceptibility of the pigmented and nonpigmented layers with the pigmented layers being affected earliest and the nonpigmented epithelium altered subsequently. The recovery of this epithelial change was rapid and complete and demonstrated the transient effects of PG on the ciliary epithelium with recovery of the blood-aqueous function by 8 hours after injection.

Immunoperoxidase localization of herpes zoster virus and simian virus 40 in cell culture.

The immunoperoxidase technique was used in an electron microscopy study to localize the virions of herpes zoster virus and simian virus 40 in cell cultures. Intranuclear and intracytoplasmic virions of herpes zoster virus were easily and specifically identified due to intense staining by the finely granular, black reaction product. With simian virus 40, intranuclear virions were not stained, whereas intracytoplasmic particles appeared densely black. There was essentially no background staining. Advantages of this technique over the ferritin-labeled antibody method include simpler preparative procedures for reagents, greater penetrability of the antibody conjugate, and internal amplification which substantially improves the ability to localize sites of antigen-antibody reaction. We believe that the immunoperoxidase method can be successfully applied to a wide variety of problems involving viral antigens.