FHIRChain: Applying Blockchain to Securely and Scalably Share Clinical Data

Secure and scalable data sharing is essential for collaborative clinical decision making. Conventional clinical data efforts are often siloed, however, which creates barriers to efficient information exchange and impedes effective treatment decision made for patients. This paper provides four contributions to the study of applying blockchain technology to clinical data sharing in the context of technical requirements defined in the "Shared Nationwide Interoperability Roadmap" from the Office of the National Coordinator for Health Information Technology (ONC). First, we analyze the ONC requirements and their implications for blockchain-based systems. Second, we present FHIRChain, which is a blockchain-based architecture designed to meet ONC requirements by encapsulating the HL7 Fast Healthcare Interoperability Resources (FHIR) standard for shared clinical data. Third, we demonstrate a FHIRChain-based decentralized app using digital health identities to authenticate participants in a case study of collaborative decision making for remote cancer care. Fourth, we highlight key lessons learned from our case study

Reply to Comment on "Cosmic rays, carbon dioxide, and climate"

In our analysis [Rahmstorf et al., 2004], we arrived at two main conclusions: the data of Shaviv and Veizer [2003] do not show a significant correlation of cosmic ray flux (CRF) and climate, and the authors' estimate of climate sensitivity to CO2 based on a simple regression analysis is questionable. After careful consideration of Shaviv and Veizer's comment, we want to uphold and reaffirm these conclusions. Concerning the question of correlation, we pointed out that a correlation arose only after several adjustments to the data, including shifting one of the four CRF peaks and stretching the time scale. To calculate statistical significance, we first need to compute the number of independent data points in the CRF and temperature curves being correlated, accounting for their autocorrelation. A standard estimate [Quenouille, 1952] of the number of effective data points is urn:x-wiley:00963941:media:eost14930:eost14930-math-0001 where N is the total number of data points and r1, r2 are the autocorrelations of the two series. For the curves of Shaviv and Veizer [2003], the result is NEFF = 4.8. This is consistent with the fact that these are smooth curves with four humps, and with the fact that for CRF the position of the four peaks is determined by four spiral arm crossings or four meteorite clusters, respectively; that is, by four independent data points. The number of points that enter the calculation of statistical significance of a linear correlation is (NEFF− 2), since any curves based on only two points show perfect correlation; at least three independent points are needed for a meaningful result

Composition Operators and Endomorphisms

If $b$ is an inner function, then composition with $b$ induces an endomorphism, $\beta$, of $L^\infty(\mathbb{T})$ that leaves $H^\infty(\mathbb{T})$ invariant. We investigate the structure of the endomorphisms of $B(L^2(\mathbb{T}))$ and $B(H^2(\mathbb{T}))$ that implement $\beta$ through the representations of $L^\infty(\mathbb{T})$ and $H^\infty(\mathbb{T})$ in terms of multiplication operators on $L^2(\mathbb{T})$ and $H^2(\mathbb{T})$. Our analysis, which is based on work of R. Rochberg and J. McDonald, will wind its way through the theory of composition operators on spaces of analytic functions to recent work on Cuntz families of isometries and Hilbert $C^*$-modules

Oral mucosal injury caused by mammalian target of rapamycin inhibitors: emerging perspectives on pathobiology and impact on clinical practice.

In recent years oral mucosal injury has been increasingly recognized as an important toxicity associated with mammalian target of rapamycin (mTOR) inhibitors, including in patients with breast cancer who are receiving everolimus. This review addresses the state-of-the-science regarding mTOR inhibitor-associated stomatitis (mIAS), and delineates its clinical characteristics and management. Given the clinically impactful pain associated with mIAS, this review also specifically highlights new research focusing on the study of the molecular basis of pain. The incidence of mIAS varies widely (2-78%). As reported across multiple mTOR inhibitor clinical trials, grade 3/4 toxicity occurs in up to 9% of patients. Managing mTOR-associated oral lesions with topical oral, intralesional, and/or systemic steroids can be beneficial, in contrast to the lack of evidence supporting steroid treatment of oral mucositis caused by high-dose chemotherapy or radiation. However, steroid management is not uniformly efficacious in all patients receiving mTOR inhibitors. Furthermore, technology does not presently exist to permit clinicians to predict a priori which of their patients will develop these lesions. There thus remains a strategic need to define the pathobiology of mIAS, the molecular basis of pain, and risk prediction relative to development of the clinical lesion. This knowledge could lead to novel future interventions designed to more effectively prevent mIAS and improve pain management if clinically significant mIAS lesions develop

Delivering reform in English healthcare: an ideational perspective

A variety of perspectives has been put forward to understand reform across healthcare systems. Recently, some have called for these perspectives to give greater recognition to the role of ideational processes. The purpose of this article is to present an ideational approach to understanding the delivery of healthcare reform. It draws on a case of English healthcare reform – the Next Stage Review led by Lord Darzi – to show how the delivery of its reform proposals was associated with four ideational frames. These frames built on the idea of “progress” in responding to existing problems; the idea of “prevailing policy” in forming part of a bricolage of ideas within institutional contexts; the idea of “prescription” as top-down structural change at odds with local contexts; and the idea of “professional disputes” in challenging the notion of clinical engagement across professional groups. The article discusses the implications of these ideas in furthering our understanding of policy change, conflict and continuity across healthcare settings