Original Blueprint Research Articles

Neurocardiology: translational advancements and potential.

In our original white paper published in the The Journal of Physiology in 2016, we set out our knowledge of the structural and functional organization of cardiac autonomic control, how it remodels during disease, and approaches to exploit such knowledge for autonomic regulation therapy. The aim of this update is to build on this original blueprint, highlighting the significant progress which has been made in the field since and major challenges and opportunities that exist with regard to translation. Imbalances in autonomic responses, while beneficial in the short term, ultimately contribute to the evolution of cardiac pathology. As our understanding emerges of where and how to target in terms of actuators (including the heart and intracardiac nervous system (ICNS), stellate ganglia, dorsal root ganglia (DRG), vagus nerve, brainstem, and even higher centres), there is also a need to develop sensor technology to respond to appropriate biomarkers (electrophysiological, mechanical, and molecular) such that closed-loop autonomic regulation therapies can evolve. The goal is to work with endogenous control systems, rather than in opposition to them, to improve outcomes.

The Relationship between Self-Efficacy and Attitude of Measurement and Evaluation: Mediating Role of Hope and Life Satisfaction

Education is the foundation of everything. Teachers are the primary builders of quality education. The quality of education is enhanced by preparation before education, coordinated management of the education process, and reliable measurement and evaluation of educational outcomes. In this context, teachers’ attitudes towards measurement and evaluation play a significant role in quality education. Cognitive and affective characteristics are crucial factors that influence teachers’ or candidates’ attitudes toward measurement and evaluation. The present study is unique in its development of a hypothetical model to examine the relationships among self-efficacy, attitude of measurement and evaluation, hope, and satisfaction. The study sample consisted of 534 individuals from Turkey, with 351 women and 183 men aged 18-25. Convenience sampling was used to select the participants, which is a non-probability sampling method that involves selecting participants who are easily accessible to the researcher. In this case, the participants were university students from Turkey who were recruited via Google Forms. Participants completed the Self-Efficacy Scale, the Hope Scale, the Life Satisfaction Scale, and the Attitude of Measurement and Evaluation Scale. Mediation analysis was conducted using Hayes’ (2017) process macro. The findings of the study support the proposed model, which suggests that hope and life satisfaction mediate the relationship between self-efficacy and attitude of measurement and evaluation. In other words, as individuals’ hope and life satisfaction increase, their self-efficacy and attitude of measurement and evaluation also increase. The conceptual framework presented within this research demonstrates considerable potential as a pioneering approach for academic exploration. This framework may potentially function as an original blueprint for scholars within the discipline. Both professionals and academics can utilize the conclusions drawn from this study to formulate psycho educational interventions with a wellness emphasis, directed at individuals. These interventions aspire to augment the self-efficacy, hope, and life satisfaction of university students.

BIM-based architectural analysis and optimization for construction 4.0 concept (a comparison)

The growing need for electricity has put Pakistan's burgeoning economy in peril. The notion of “Construction 4.0″ is considered in this study since it enables the greatest utilization of energy and architectural analysis. A case study and a method for building information modelling are used to analyze the concepts of green building. The case study building is represented as a parametric model using the Autodesk Revit platform with the original blueprints and data. Using Autodesk Insight 360, an energy analysis and comparison of optimization case study of the A-Block and Z-Block COMSATS Abbottabad, Pakistan is chosen. This study analyses an academic building's energy performance as a case study to reduce energy usage. By turning the building 360 degrees at 45-degree intervals and utilizing BIM to install energy-efficient construction materials, this study analyses the energy efficiency of an academic building. The average annual energy cost for blocks A and Z is decreased from 228 kWh/m2 to 160 kWh/m2 and 192 kWh/m2, respectively.

MONITORING WORK PROGRESS OF DAM CONSTRUCTION BASED ON PHOTOGRAMMETRIC POINT CLOUDS AND BIM: PRACTICAL APPROACH TO TEACHING INDUSTRY

Abstract. Industry 4.0 encompasses a range of ideas, technologies, and procedures that impact engineering education and other fields. Building information modeling (BIM) has become a widely adopted practice in Indonesia's construction industry, prompting polytechnic universities to incorporate BIM skills and concepts into their construction engineering and management degree programs. Nowdays, more than 50 dam construction works occurred in Indonesia from 2014-2024. Monitoring progress regularly is crucial to ensure a construction project's successful completion. This can be done by visually tracking the project's advancement, which enables the identification of any changes or deviations that occur. Accurate measurement data is essential for reliable progress management, as it allows for the prediction of future project success or failure. Image-based object detection is highly beneficial for retrieving site information and monitoring construction progress. To monitor the progress of a construction project, comparisons between the building's as-built and as-planned states are necessary. BIM is employed to establish the intended condition of a building by providing information regarding its geometric characteristics and construction schedule. In this paper, we present a novel method for producing a point cloud that accurately represents the dam building site using photogrammetry. To overcome the limitation of capturing photographs from every possible angle at a construction site, we employ a combination of structure from motion and control points. This approach allows us to generate a scaled point cloud in a standardized coordinate system. The building's as-built and as-planned states are then compared using this point cloud. Structure from Motion (SfM) disparity maps are fused to create dense point clouds, which are then compared to the goal state for updating 4D BIM. This makes it possible to identify missing building components. To validate the presence of building elements, a secondary examination is conducted using the positions in front of and behind the model planes constructed as per the original blueprint. The research paper explores potential approaches and presents empirical results obtained from an actual case study.

The Borderlands

The Borderlands

Roadmap to Reasoning in Microservice Systems: A Rapid Review

Understanding software systems written by others is often challenging. When we want to assess systems to reason about them, i.e., to understand dependencies, analyze evolution trade-offs, or to verify conformance to the original blueprint, we must invest broad efforts. This becomes difficult when considering decentralized systems. Microservice-based systems are mainstream these days; however, to observe, understand, and manage these systems and their properties, we are missing fundamental tools that would derive various simplified system abstract perspectives. Microservices architecture characteristics yield many advantages to system operation; however, they bring challenges to their development and deployment lifecycles. Microservices urge a system-centric perspective to better reason about the system evolution and its quality attributes. This process review paper considers the current system analysis approaches and their possible alignment with automated system assessment or with human-centered approaches. We outline the necessary steps to accomplish holistic reasoning in decentralized microservice systems. As a contribution, we provide a roadmap for analysis and reasoning in microservice-based systems and suggest that various process phases can be decoupled through the introduction of system intermediate representation as the trajectory to provide various system-centered perspectives to analyze various system aspects. Furthermore, we cover different technical-based reasoning strategies and metrics in addition to the human-centered reasoning addressed through alternative visualization approaches. Finally, a system evolution is discussed from the perspective of such a reasoning process to illustrate the impact analysis evaluation over system changes.

НЕМЕЦКАЯ АРХИТЕКТУРА В РОССИИ: ГЕРМАН МУТЕЗИУС И ЭЛЕКТРОСТАНЦИЯ «ЭЛЕКТРОПЕРЕДАЧА» (1914)

The “Electroperedacha” (Electric Transmission) power plant represents an important attainment in the field of architecture, urban planning and power engineering. This plant has been in operation since 1914 to the present day. Based on the original blueprints the authorship of the project was identified – it was created by Hermann Muthesius, the co-founder of the Deutsche Werkbund. The article provides a greater knowledge of the Muthesius’s heritage due to the discovery of his first and the only one project in Russia. Furthermore, the article examines the modernization of the plant in the 1920s with the participation of the VKHUTEMAS Architecture Faculty Dean Edgar Norvert. At the beginning of the 20th century, in Germany, Werkbund masters elaborated a new approach to the architecture based on the unity of art and industry. The research regards the close relationship between Russia and Germany in the field of electrification, owing to which the creation of the “Electroperedacha” power plant became possible. To conclude, the preservation and revitalization of industrial architecture is an important social and cultural process, and this published information can be regarded as a contribution to it.

Abstract PD6-02: Digital MammaPrint and BluePrint using machine learning and whole slide imaging

Abstract Background: The rise of whole slide imaging systems has enabled pathologists to remotely view cases in high resolution to diagnose cancer, and efficiently archive images . The advent of machine learning techniques and their application in digital pathology have facilitated the identification of histological patterns for effective diagnosis of disease. Deep learning-based solutions have been developed to detect and recognize cancer types, and automatically grade and stage tumors through evaluation of pathological features and patterns. However, no image-based solutions have been able to replicate a multivariate test, such as a risk -of recurrence assay for early stage breast cancer. Traditionally, subtle differences in gene expression have been measured by microarray or NGS, however these changes may also be recognized phenotypically from hematoxylin and eosin stained (H&E) slides by digital biomarkers developed using novel machine learning techniques. The large repository of images with MammaPrint and BluePrint results may enable us to develop digital MammaPrint and digital BluePrint biomarkers that predict the risk of distant recurrences and the molecular subtypes of a tumor sample using only H&E stained digitized tumor slides. Methods: Using over70,000 H&E images of early stage breast cancer patients in combination with machine learning techniques, digital versions of MammaPrint and BluePrint were developed. In total 20,000 images were used for feasibility and algorithm optimization, another 50,000 images were used for further finetuning. MammaPrint indices and BluePrint scores and categorical results were used to train the system. After the algorithms were optimized, they were locked and validated in an independent set of 5000 H&E stained images. The MammaPrint and BluePrint predictions were compared to the original MammaPrint and BluePrint results obtained from the microarray assay. The finalized and locked algorithms were further validated for precision and reproducibility in a large data set of xx Images and processed multiple times. Multicenter clinical validation was performed in H&E stained images of multiple series with long term follow up (tbd), totaling ##k images. In this ##K cohort of patients, #% were HR+/HER2-, #% were clinically HER2+ and x% were triple negative. Results: Using an independent dataset of 5000 samples, we compared the MammaPrint and BluePrint predictions obtained from the H&E slides to the traditional versions of MammaPrint and BluePrint based on a microarray. The binary performance of the digital MammaPrint had a concordance of xx% (with an AUC of xx%),%NPA and %PPA when compared to the traditional MammaPrint high-low classification. For digital BluePrint, the system had a concordance of xx% and a classification accuracy of xx%. The analytical performance showed a precision and reproducibility of xx% In a multicenter clinical validation the DRFI was xx% in dMP low risk and yy% in dMP high risk groups. The xxx dataset the performance was similar to the microarray and better than compared to clinical parameters. Analyses will be available by the Placeholder Abstract deadline. Conclusions: The combination of machine learning and digital pathology has enabled development of rapid and highly accurate in silico versions of MammaPrint and BluePrint. Implementation of digital H&E based risk of recurrence and molecular subtyping could enable preservation of valuable diagnostic tissue, faster turnaround time for test results, and a more cost effective approach to treatment planning tools, especially in countries that do not allow send out of human tissue and this adoption of risk scoring is low. Final conclusions tbd Citation Format: Annuska M Glas, Jorge S Reis-Filho, Diederik Wehkamp, Belma Dodgas, Leonie Delahaye, Ran Godrich, Jeroen Mollink, Adam Casson, Anke Witteveen, Julian Viret, Donghun Lee, Matthew Lee, Hugo Horlings, Leo Grady, Thomas Fuchs, William Audeh, Christopher Kanan, Laura J van't Veer. Digital MammaPrint and BluePrint using machine learning and whole slide imaging [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD6-02.

A coevolutionary perspective on decentralised electrification: a solar mini-grid project in India

Decentralised mini-grids can support household electrification needs in remote rural communities in developing countries. Adopting a practice-oriented perspective to research, we describe our experience in implementing a decentralised solar mini-grid project in India over a period of three years. Focusing on processes, we demonstrate how technical design, organisational mandates and project contingencies coevolve with business strategies, user practices, local institutions and ecosystems. Recognising and facilitating coevolution between systems can have important causal impacts on project outcomes. In our case, the project deviates from the original blueprint towards a higher technical design value, service-based tariffs, and greater time and resource investment by the implementing agency. The coevolutionary perspective has been used previously as an analytical tool. We propose here that it can also serve as a practical how-to guide for micro-level projects by alerting implementers to the requirements of greater time, resources and community engagement.

Commemorating the 50th anniversary of the Freeze and Harlan (1969) Blueprint for a physically-based, digitally-simulated hydrologic response model

The year 2019 marks the 50th anniversary of a pioneering publication in hydrology. Allan Freeze and Richard Harlan published their Blueprint for a physically-based, digitally-simulated hydrologic response model (Freeze and Harlan, 1969) in this journal. Their vision was for a futuristic model that would integrate key processes and compartments in the hydrologic cycle: precipitation, evapotranspiration, overland runoff, infiltration and groundwater exchange (into and out of) surface water bodies, such as rivers and lakes. Today, the original Blueprint is a reality. Our paper commemorates the 50 year anniversary of the original Blueprint paper. Through personal communications with Allan Freeze, we document the history and genesis of this paper for the first time. We reflect on the uptake of the Blueprint into modern hydrology, the development of numerical models that enabled this, and the range of challenges being tackled by these models. Finally, we consider challenges and opportunities for the future of this area of modelling and hydrologic science.

Genome to Phenome: Improving Animal Health, Production, and Well-Being - A New USDA Blueprint for Animal Genome Research 2018-2027.

In 2008, a consortium led by the Agricultural Research Service (ARS) and the National Institute for Food and Agriculture (NIFA) published the “Blueprint for USDA Efforts in Agricultural Animal Genomics 2008–2017,” which served as a guiding document for research and funding in animal genomics. In the decade that followed, many of the goals set forth in the blueprint were accomplished. However, several other goals require further research. In addition, new topics not covered in the original blueprint, which are the result of emerging technologies, require exploration. To develop a new, updated blueprint, ARS and NIFA, along with scientists in the animal genomics field, convened a workshop titled “Genome to Phenome: A USDA Blueprint for Improving Animal Production” in November 2017, and these discussions were used to develop new goals for the next decade. Like the previous blueprint, these goals are grouped into the broad categories “Science to Practice,” “Discovery Science,” and “Infrastructure.” New goals for characterizing the microbiome, enhancing the use of gene editing and other biotechnologies, and preserving genetic diversity are included in the new blueprint, along with updated goals within many genome research topics described in the previous blueprint. The updated blueprint that follows describes the vision, current state of the art, the research needed to advance the field, expected deliverables, and partnerships needed for each animal genomics research topic. Accomplishment of the goals described in the blueprint will significantly increase the ability to meet the demands for animal products by an increasing world population within the next decade.

The Afghan Local Police: unpacking a hybrid security arrangement

Our article takes issue with some applications of ‘hybridity’ in contemporary peace studies. We want to correct the view of ‘hybridity’ as mere expressions of resistance by the local to the external interventionist blueprints. We make our case based on field research of a community defence programme developed by the US military to address weaknesses in the Afghan state. Our critical reconstruction of ‘hybridity’ to two provincial studies presses the need to encompass the co-construction of hybrid outcomes, the fluidity of the process and complexities in the local context that shape the choices of both local and international actors. We argue that negative local experiences with the Afghan Local Police can be attributed to elite capture and pragmatic adaptations to the logic of the battle field. We further suggest that even ‘prescribed’ hybridity can work when the context matches the assumptions and conditions outlined in the original blueprint. Our analysis highlights the dangers of simplifying the local and cautions against scaling-up context-specific hybrid security mechanisms to a national level in a diverse and competitive environment such as Afghanistan.

「荒玉水道」の当初設計図となる『荒玉水道図』について

This paper introduces the Aratama-suido-zu (“zu” meaning original blueprints) proposal for the Aratama-suido project to supply water in Tokyo’s Aratama District. Construction began in 1926, but in 1927, Japan’s government called for the project to be scaled back. The revised Aratama-suido was presented in the 1931 Aratama-suido-shi (“shi” meaning official document). The Aratama-suido-shi noted the number and locations of the project’s buildings in both the original and revised plans, but not the original designs for the buildings. This has made it difficult to compare them with the final designs, though attempts have been made (Masuda, 2006). The author clarifies the original designs, revealing how the engineers’ thought processes evolved.

The European Social Survey: Contents, Design, and Research Potential

Following its establishment in 2001, the academically led European Social Survey (ESS) has become one of the most important and informative resources concerning a broad variety of European populations’ moral, religious, social, economic and political attitudes and behaviours. In addition to its primary goal of tracking changes and stability in European citizens’ attitudes and behaviours, the ESS project also devotes itself to the development and dissemination of advanced standards in survey research. In particular, this applies to questionnaire design, cross-national equivalence of the instruments used and the sampling procedures applied (Jowell et al., 2007; Kohler, 2007; 2008). Designed as a biennial survey in its original blueprint, the ESS has by now been conducted in more than 30 European countries and currently offers data from the first six waves of the survey (2002–2012), including information and answers of approximately 300,000 respondents in total (at the time of writing, fieldwork for the seventh wave of the ESS has just been completed). Its integration of a variety of socially relevant topics, broad coverage of European countries and a growing number of time points make the ESS an increasingly suitable data source for single-country as well as cross-national analyses with time-series analysis now starting to become feasible. For policy makers and scholars from various disciplines and fields of interest alike, the ESS therefore provides a unique and innovative resource on the (changing) social, political and economic conditions in Europe at the outset of the 21 century.

Inside Oregon State Hospital: A History of Tragedy and Triumph by Diane L. Goeres-Gardner John Terry

 Reviews photographs, and the images that appear are often muddy. Maps of each of Burg’s journeys also would have been helpful. Nonetheless, The Last Voyageur will interest white-water enthusiasts,armchair adventurers,and anyone interested in the history of outdoor recreation and wilderness. Marsha Weisiger University of Oregon Inside Oregon State Hospital: A History of Tragedy and Triumph by Diane L. Goeres-Gardner foreword by John Terry The History Press, Charleston, South Carolina, 2013. Illustrations, tables, notes, index. 334 pages. $21.99 paper. During the 1960s and 1970s, policies of deinstitutionalization emptied state hospitals across the nation. Subsequent changes in federal funding and state budget cuts led to such neglect of Oregon State Hospital (OSH) that it was nearly wiped off the map. Thanks to Oregonians who care about their historic buildings, a portion of the 1883 “J” building was saved from demolition and now houses the Museum of Mental Health. Inside Oregon State Hospital likewise compiles and preserves the history of the 130-yearold institution — including the buildings on the 140-acre campus and the recently completed hospital adjacent to the “J” building, as well as photographs and case histories that illustrate the hospital’s sometimes contradictory role in patient care. The history of Oregon State Hospital is the evolution of mental health policy in Oregon. Mental illness is a colloquial term used to encompass many diverse and complex conditions .Society’sresponse to those conditionshas been to stigmatize, leading the medical field to experiment with many different solutions.The stigma of mental illness has,at times,extended to the institutions responsible for treating it. Diane L. Goeres-Gardner’s even-handed and well-documented approach makes it difficult to paint patients or institutions with a broad brush. For scholars, the author provides copious footnotes at the end of each chapter. Her references include state archives, newspaper articles,admission and death records,biennial reports from the hospital to the legislature,correspondence between hospital administrators and the Board of Control, personal papers of superintendents, and recent interviews. For more casual readers,the well-researched details and frequent photographs bring history to life. Especially helpful is a map of the hospital campus as it appeared before demolition (2010) and after reconstruction (2012), a list of superintendents and their terms of employment,and a timeline of significant events from 1843 to 2012. Also included are the original blueprints of the“J”building and descriptions of the tunnel system and the Cottage Farm and dairy. The chapters are built around the case histories of people who would become patients,the aspirations and innovations of the physicians who would supervise them, and the legislation that would affect them. Progressing more or less chronologically, the chapters reveal the evolution of treatment philosophies and modalities from moral management to milieu therapy and psychoanalysis to shock therapies, eugenics, and finally lobotomies to psychotropic medication. Evident throughout the chapters is the dilemma that may be intrinsic to publicly supported institutions: how to accommodate an ever-increasing census while keeping costs as low as possible. That struggle plays out repeatedly as each superintendent takes steps  OHQ vol. 115, no. 2 to increase discharges or to limit admissions. Cost containment also takes the form of low employee wages, long days, and low staff-topatient ratios. At times, severe overcrowding leads to security problems and the increased use of mechanical restraints. In her introduction,Goeres-Gardner makes the argument that “asylums were the epitome of the patriarchal system” and that “as the superintendent used his authority over the patients, the state used its authority over the superintendents” (p. 15). She goes on to say that“this power structure led ultimately to the Eugenics Movement. . . the various shock treatments and the permanent cure, lobotomy” (p. 15). While this is no doubt true, cultural influencesandpublicopinionshouldnotbeignored or underestimated. The eugenics movement philosophy, popular nationally during the mid 1920s through 1940s, appeared in Oregon newspapers as early as 1907 and was officially recognized in Oregon by the Board of Eugenics in1917.In2002,Gov.JohnKitzhaberapologized on behalf of the state for the outcomes of its eugenics policies that affected thousands of Oregonians (p. 167). In chapter 10, “In and Out of the Cuckoo’s Nest,” the...

Exile and the City F. Scott Fitzgerald's “The Lost Decade”

Exile and the City F. Scott Fitzgerald's “The Lost Decade”

Reclaiming the Political in Bosnia: A Critique of the Legal-Rational Nightmare of Contemporary Bosnian Statehood

Across the asphalt and concrete of our raped land, comes a band of profiteers, carrying away our wealth.. .Flags have been sown, the children convinced, the knives distributed, our graveyards divided.Damir Avidic, Po Asfaltu i Betonu2There a popular joke in concerning the dealings of Milorad Dodik, the President of the Serb-dominated Republika Srpska (RS) entity within Bosnia-Herzegovina, which says as much about Dodik as it does about the general state of affairs in the country as a whole. As the story goes, Dodik visits the (now former) Prime Minister of Italy, Silvio Berlusconi, in a fabulous villa just outside of Rome. Dodik dazzled by the splendour of the Prime Minister's manse and inquires how, as a public servant, Berlusconi had managed to live in such luxury. Berlusconi takes Dodik to a secluded balcony and shows him a sprawling highway off in the distance. He explains that through some clever bookkeeping, he and his associates had managed to shave two centimeters off each side of the road from what the original blueprints had called for, and in the process had saved millions - which they had then pocked for themselves and hence his impressive home. A few months later, it Berlusconi visiting Dodik and upon his arrival, the Italian can scarce believe his eyes; Dodik's mansion easily twice the size of his own and immeasurably more luxurious. Berlusconi pleads with Dodik to explain how he managed to find the funds to build such a home and, obliging, taken to a large bay window overlooking the countryside. Do you see our fabulous new highway, Silvio? No, all I see empty fields. Exactly!The above as telling and succinct of a narrative about the general state of Bosnian society as one likely to find. After all, BosniaHerzegovina a country where even respected academics and policy analysts are forced to concede that it is a great place to be a politician but a shitty place to be a citizen (Siddiqui 2011). Yet with more government ministers, bureaucrats and international administrators of various sorts than countries many times its size, trudging across its cities, towns, villages and hamlets, utterly lacks any meaningful, popular mobilization. The weight of post-war Bosnian politics has instead served to depoliticize the people of the area; it has made them beholden to the machinations of local and foreign oligarchs.Newspapers in Bosnia's three main cities (Sarajevo, Banja Luka and Mostar), most catering to one of the country's three constitutive peoples (Bosniaks, Serbs and Croats), report with breathless regularity on the latest in scandalous pronouncements. The bombastic nationalist rhetoric of Dodik a popular theme amongst the Sarajevo papers, for example, who react with fury at his weekly suggestions that Bosnia a failed experiment or his frequent negations of genocide in the country during the 1990s (Dervisbegovic 2011). These statements are declared as unacceptable, in turn, by the representatives of the international community in Bosnia-Herzegovina, the Office of the High Representative (OHR) as well as the European Union Special Representative, and the subsequent exchanges reported on with equally repetitive and vapid zeal (Tanjug 2011). The process begins anew the next week.Meanwhile, substantive dialogue or mobilization almost entirely absent, despite the steadily deteriorating standard of living for all Bosnians, regardless of ethnicity. The handful of dominant parties in the country, most of which are exclusively ethno-nationalist in orientation, have managed to sequester the realm of political action to their theatrical antagonisms - what locals refer to as nacionalisticko prepucavanje: hackneyed nationalist bickering or trolling. Said theatrics, of course, and as our earlier joke suggested, are widely understood to be the front operations for the actual day-to-day routine of Bosnian economy: corruption on an endemic scale, orchestrated by nationalist oligarchs, which has resulted in the systematic dispossession of even the meagre social wealth and infrastructure that survived the war (Corruption 'Humongous' in 2008). …

China and the Changing Myanmar

The author argues that the democratic reform in Myanmar is rooted in profound internal and external factors. Since the beginning of the reform, the changes in Myanmar have taken tolls in a series of China's existing interests inside the country. Economically, Chinese investments have come under increasing scrutiny, criticism, and even oppositions, threatening the viability of strategic projects such as the oil and gas pipelines. Politically, the initial success of the democratic reform in Myanmar raises questions about Beijing's continuous resistance to reform. Strategically, the changes in Myanmar undercut China's original blueprint about the strategic utilities of Myanmar for China at ASEAN, in the Indian Ocean and more broadly in the region. In light of the changes, China has adjusted its policy toward Myanmar. Not only has Beijing dramatically reduced its economic investments in Myanmar, it also cooled down the political ties while established relations with the democratic oppositions. At the same time, China also launched massive public relations campaigns inside Myanmar aimed at improving its image and relations with the local communities.

Remote doctoring is only part of online health

In England, the use of everyday technologies to provide easier access to urgent care and to improve health began at scale in the late 1990s with the telephone. Over the past 12 years, remote health advice and information have become an established part of the NHS scene. 2010 was the first year in which more people contacted NHS Direct over the Internet than by telephone. That trend is expected to continue as smartphones become ubiquitous, as more tools become available for people to self-serve online, and as we continue to learn how and where these approaches add most value for patients and the NHS. Reports that Professor Sir Bruce Keogh is drawing up plans to introduce online consultations1 are very welcome. But experience clearly shows that, in health as in other sectors, the transformative effect of the web does not lie primarily in opening up new channels for traditional interactions. Its greatest power is to enable safe, high quality self-service, underpinned by the best available medical expertise, to support patients themselves to manage their health and make better informed decisions about their care. It is commonplace now to look at retail banking as an indicator of how technology can drive new business models, improving customer experience and reducing cost by harnessing people's willingness to do things for themselves. In retail banking, the creation of digital services has enabled rationalization of the physical estate, something the NHS badly needs. Between 2000 and 2010, the number of UK customers registered for telephone banking increased from 16 m to 46 m but began to fall from their peak in 2006. Over the same period, online bank accounts multiplied from 1.4 m to 40 m and continued to rise beyond 2010, approaching the telephone as the leading remote channel. Meanwhile the number of high street branches fell from over 12,000 to under 10,000.2 The revolution in banking has not come about through replacing visits to the branch with remote access to clerks and managers by telephone or web, but through technology-enabled self-service. The debate about remote consultations now starting in the NHS is reminiscent of the banking sector in the 1990s. Over several years, the senior leaders in a major retail and business bank developed a blueprint for the banking of the future. They envisaged technology instantly bringing a range of data feeds to lending officers’ desktops, including economic forecasts, both local and national; business sector performance; and personal credit history – essentially using digital resources to augment the traditional model of thousands of lending decisions by individual experts. The technology to support this vision turned out to be relatively expensive and slow in coming. Meanwhile, in the back offices, a real revolution was taking place as analysts, statisticians and programmers developed the software that automated decision-making and provided self-service credit decisions for millions of customers, rendering the original blueprint obsolete before it ever materialized. The NHS's early attempts at remote self-service have shown themselves to be safe and popular with patients. In 2009, the National Pandemic Flu Service (NPFS) carried out 2.7 million remote assessments, enabling 1.8 million people to access prescription-only antiviral medication without seeing or even speaking to a qualified health professional.3 Forty percent of these assessments were self-service over the web. The safety and effectiveness of the NPFS did not depend on individual judgements by the hundreds of staff around the country who were rapidly recruited and trained in response to the pandemic, but on the medical expertise embedded within the assessment algorithm. Day by day and week by week, as researchers learned more about the virus, the algorithm was updated in real time, giving every patient the benefit of the most up-to-date medical knowledge, wherever they happened to be. Similarly, the power of NHS Direct's suite of 40+ digital symptom assessment tools lies in the quality of the medical expertise which underpins them, coupled with growing experience in how to apply consumer digital techniques to present health information and support decision-making online. The symptom checkers have now been used over 12 million times,4 and the mobile apps launched in May 2011 have been used over a million times. Continuous careful monitoring of adverse incidents gives no reason to believe that these digital tools threaten patient safety. We are just beginning to see the benefits of people taking the technologies they use every day, and applying them to manage their health. The rapid adoption that we have seen of digital health tools by consumers, will increasingly enable high cost face-to-face and physical resources to be devoted to the people and situations that need them. The greatest potential is the use of technology to support patient self-management so, while supporting remote doctoring, we need to take care that it does not become a distraction from the real prize.

Northern Ontario School of Medicine

Northern Ontario School of Medicine