Using technology to teach technology: design and evaluation of bilingual online physician education about electronic medical records.

The "EMR Tutorial" is designed to be a bilingual online physician education environment about electronic medical records. After iterative assessment and redesign, the tutorial was tested in two groups: U.S. physicians and Mexican medical students. Split-plot ANOVA revealed significantly different pre-test scores in the two groups, significant cognitive gains for the two groups overall, and no significant difference in the gains made by the two groups. Users rated the module positively on a satisfaction questionnaire.

A reconstruction of radiocarbon production and total solar irradiance from the Holocene ¹⁴C and CO₂ records: implications of data and model uncertainties

Radiocarbon production, solar activity, total solar irradiance (TSI) and solar-induced climate change are reconstructed for the Holocene (10 to 0 kyr BP), and TSI is predicted for the next centuries. The IntCal09/SHCal04 radiocarbon and ice core CO2 records, reconstructions of the geomagnetic dipole, and instrumental data of solar activity are applied in the Bern3D-LPJ, a fully featured Earth system model of intermediate complexity including a 3-D dynamic ocean, ocean sediments, and a dynamic vegetation model, and in formulations linking radiocarbon production, the solar modulation potential, and TSI. Uncertainties are assessed using Monte Carlo simulations and bounding scenarios. Transient climate simulations span the past 21 thousand years, thereby considering the time lags and uncertainties associated with the last glacial termination. Our carbon-cycle-based modern estimate of radiocarbon production of 1.7 atoms cm−2 s−1 is lower than previously reported for the cosmogenic nuclide production model by Masarik and Beer (2009) and is more in-line with Kovaltsov et al. (2012). In contrast to earlier studies, periods of high solar activity were quite common not only in recent millennia, but throughout the Holocene. Notable deviations compared to earlier reconstructions are also found on decadal to centennial timescales. We show that earlier Holocene reconstructions, not accounting for the interhemispheric gradients in radiocarbon, are biased low. Solar activity is during 28% of the time higher than the modern average (650 MeV), but the absolute values remain weakly constrained due to uncertainties in the normalisation of the solar modulation to instrumental data. A recently published solar activity–TSI relationship yields small changes in Holocene TSI of the order of 1 W m−2 with a Maunder Minimum irradiance reduction of 0.85 ± 0.16 W m−2. Related solar-induced variations in global mean surface air temperature are simulated to be within 0.1 K. Autoregressive modelling suggests a declining trend of solar activity in the 21st century towards average Holocene conditions.

High-resolution mineral dust and sea ice proxy records from the Talos Dome ice core

In this study we report on new non-sea salt calcium (nssCa2+, mineral dust proxy) and sea salt sodium (ssNa+, sea ice proxy) records along the East Antarctic Talos Dome deep ice core in centennial resolution reaching back 150 thousand years (ka) before present. During glacial conditions nssCa2+ fluxes in Talos Dome are strongly related to temperature as has been observed before in other deep Antarctic ice core records, and has been associated with synchronous changes in the main source region (southern South America) during climate variations in the last glacial. However, during warmer climate conditions Talos Dome mineral dust input is clearly elevated compared to other records mainly due to the contribution of additional local dust sources in the Ross Sea area. Based on a simple transport model, we compare nssCa2+ fluxes of different East Antarctic ice cores. From this multi-site comparison we conclude that changes in transport efficiency or atmospheric lifetime of dust particles do have a minor effect compared to source strength changes on the large-scale concentration changes observed in Antarctic ice cores during climate variations of the past 150 ka. Our transport model applied on ice core data is further validated by climate model data. The availability of multiple East Antarctic nssCa2+ records also allows for a revision of a former estimate on the atmospheric CO2 sensitivity to reduced dust induced iron fertilisation in the Southern Ocean during the transition from the Last Glacial Maximum to the Holocene (T1). While a former estimate based on the EPICA Dome C (EDC) record only suggested 20 ppm, we find that reduced dust induced iron fertilisation in the Southern Ocean may be responsible for up to 40 ppm of the total atmospheric CO2 increase during T1. During the last interglacial, ssNa+ levels of EDC and EPICA Dronning Maud Land (EDML) are only half of the Holocene levels, in line with higher temperatures during that period, indicating much reduced sea ice extent in the Atlantic as well as the Indian Ocean sector of the Southern Ocean. In contrast, Holocene ssNa+ flux in Talos Dome is about the same as during the last interglacial, indicating that there was similar ice cover present in the Ross Sea area during MIS 5.5 as during the Holocene.

Comparison of clinical knowledge management capabilities of commercially-available and leading internally-developed electronic health records.

BACKGROUND: We have carried out an extensive qualitative research program focused on the barriers and facilitators to successful adoption and use of various features of advanced, state-of-the-art electronic health records (EHRs) within large, academic, teaching facilities with long-standing EHR research and development programs. We have recently begun investigating smaller, community hospitals and out-patient clinics that rely on commercially-available EHRs. We sought to assess whether the current generation of commercially-available EHRs are capable of providing the clinical knowledge management features, functions, tools, and techniques required to deliver and maintain the clinical decision support (CDS) interventions required to support the recently defined "meaningful use" criteria. METHODS: We developed and fielded a 17-question survey to representatives from nine commercially available EHR vendors and four leading internally developed EHRs. The first part of the survey asked basic questions about the vendor's EHR. The second part asked specifically about the CDS-related system tools and capabilities that each vendor provides. The final section asked about clinical content. RESULTS: All of the vendors and institutions have multiple modules capable of providing clinical decision support interventions to clinicians. The majority of the systems were capable of performing almost all of the key knowledge management functions we identified. CONCLUSION: If these well-designed commercially-available systems are coupled with the other key socio-technical concepts required for safe and effective EHR implementation and use, and organizations have access to implementable clinical knowledge, we expect that the transformation of the healthcare enterprise that so many have predicted, is achievable using commercially-available, state-of-the-art EHRs.

Improving follow-up of abnormal cancer screens using electronic health records: trust but verify test result communication.

BACKGROUND: Early detection of colorectal cancer through timely follow-up of positive Fecal Occult Blood Tests (FOBTs) remains a challenge. In our previous work, we found 40% of positive FOBT results eligible for colonoscopy had no documented response by a treating clinician at two weeks despite procedures for electronic result notification. We determined if technical and/or workflow-related aspects of automated communication in the electronic health record could lead to the lack of response. METHODS: Using both qualitative and quantitative methods, we evaluated positive FOBT communication in the electronic health record of a large, urban facility between May 2008 and March 2009. We identified the source of test result communication breakdown, and developed an intervention to fix the problem. Explicit medical record reviews measured timely follow-up (defined as response within 30 days of positive FOBT) pre- and post-intervention. RESULTS: Data from 11 interviews and tracking information from 490 FOBT alerts revealed that the software intended to alert primary care practitioners (PCPs) of positive FOBT results was not configured correctly and over a third of positive FOBTs were not transmitted to PCPs. Upon correction of the technical problem, lack of timely follow-up decreased immediately from 29.9% to 5.4% (p<0.01) and was sustained at month 4 following the intervention. CONCLUSION: Electronic communication of positive FOBT results should be monitored to avoid limiting colorectal cancer screening benefits. Robust quality assurance and oversight systems are needed to achieve this. Our methods may be useful for others seeking to improve follow-up of FOBTs in their systems.

Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential?

BACKGROUND: Given the fragmentation of outpatient care, timely follow-up of abnormal diagnostic imaging results remains a challenge. We hypothesized that an electronic medical record (EMR) that facilitates the transmission and availability of critical imaging results through either automated notification (alerting) or direct access to the primary report would eliminate this problem. METHODS: We studied critical imaging alert notifications in the outpatient setting of a tertiary care Department of Veterans Affairs facility from November 2007 to June 2008. Tracking software determined whether the alert was acknowledged (ie, health care practitioner/provider [HCP] opened the message for viewing) within 2 weeks of transmission; acknowledged alerts were considered read. We reviewed medical records and contacted HCPs to determine timely follow-up actions (eg, ordering a follow-up test or consultation) within 4 weeks of transmission. Multivariable logistic regression models accounting for clustering effect by HCPs analyzed predictors for 2 outcomes: lack of acknowledgment and lack of timely follow-up. RESULTS: Of 123 638 studies (including radiographs, computed tomographic scans, ultrasonograms, magnetic resonance images, and mammograms), 1196 images (0.97%) generated alerts; 217 (18.1%) of these were unacknowledged. Alerts had a higher risk of being unacknowledged when the ordering HCPs were trainees (odds ratio [OR], 5.58; 95% confidence interval [CI], 2.86-10.89) and when dual-alert (>1 HCP alerted) as opposed to single-alert communication was used (OR, 2.02; 95% CI, 1.22-3.36). Timely follow-up was lacking in 92 (7.7% of all alerts) and was similar for acknowledged and unacknowledged alerts (7.3% vs 9.7%; P = .22). Risk for lack of timely follow-up was higher with dual-alert communication (OR, 1.99; 95% CI, 1.06-3.48) but lower when additional verbal communication was used by the radiologist (OR, 0.12; 95% CI, 0.04-0.38). Nearly all abnormal results lacking timely follow-up at 4 weeks were eventually found to have measurable clinical impact in terms of further diagnostic testing or treatment. CONCLUSIONS: Critical imaging results may not receive timely follow-up actions even when HCPs receive and read results in an advanced, integrated electronic medical record system. A multidisciplinary approach is needed to improve patient safety in this area.

Climate Variability in West Antarctica Derived from Annual Accumulation-Rate Records from ITASE Firn/Ice Cores

Thirteen annually resolved accumulation-rate records covering the last similar to 200 years from the Pine Island-Thwaites and Ross drainage systems and the South Pole are used to examine climate variability over West Antarctica. Accumulation is controlled spatially by the topography of the ice sheet, and temporally by changes in moisture transport and cyclonic activity. A comparison of mean accumulation since 1970 at each site to the long-term mean indicates an increase in accumulation for sites located in the western sector of the Pine Island-Thwaites drainage system. Accumulation is negatively associated with the Southern Oscillation Index (Sol) for sites near the ice divide, and periods of sustained negative Sol (1940-42, 1991-95) correspond to above-mean accumulation at most sites. Correlations of the accumulation-rate records with sea-level pressure (SLP) and the SOI suggest that accumulation near the ice divide and in the Ross drainage system may be associated with the midlatitudes. The post-1970 increase in accumulation coupled with strong SLP-accumulation-rate correlations near the coast suggests recent intensification of cyclonic activity in the Pine Island-Thwaites drainage system.

Atmospheric Soluble Dust Records from a Tibetan Ice Core: Possible Climate Proxies and Teleconnection With the Pacific Decadal Oscillation

In autumn 2005, a joint expedition between the University of Maine and the Institute of Tibetan Plateau Research recovered three ice cores from Guoqu Glacier (33 degrees 34'37.80 '' N, 91 degrees 10'35.3 '' E, 5720 m above sea level) on the northern side of Mt. Geladaindong, central Tibetan Plateau. Isotopes ( delta(18)O), major soluble ions (Na(+), K(+), Mg(2+), Ca(2+), Cl(-), NO(3)(-), SO(4)(2-)), and radionuclide (beta-activity) measurements from one of the cores revealed a 70-year record (1935-2005). Statistical analysis of major ion time series suggests that atmospheric soluble dust species dominate the chemical signature and that background dust levels conceal marine ion species deposition. The soluble dust time series have interspecies relations and common structure (empirical orthogonal function (EOF) 1), suggesting a similar soluble dust source or transport route. Annual and seasonal correlations between the EOF 1 time series and National Centers for Environmental Prediction/National Center for Atmospheric Research reanalysis climate variables (1948-2004) suggest that the Mt. Geladaindong ice core record provides a proxy for local and regional surface pressure. An approximately threefold decrease of soluble dust concentrations in the middle to late 1970s, accompanied by regional increases in pressure and temperature and decreases in wind velocity, coincides with the major 1976-1977 shift of the Pacific Decadal Oscillation (PDO) from a negative to a positive state. This is the first ice core evidence of a potential teleconnection between central Asian atmospheric soluble dust loading and the PDO. Analysis of temporally longer ice cores from Mt. Geladaindong may enhance understanding of the relationship between the PDO and central Asian atmospheric circulation and subsequent atmospheric soluble dust loading.

Association Between Atmospheric Circulation Patterns and Firn-Ice Core Records from the Inilchek Glacierized Area, Central Tien Shan, Asia

Glacioclimatological research in the central Tien Shan was performed in the summers of 1998 and 1999 on the South Inilchek Glacier at 5100 - 5460 m. A 14.36 m firn-ice core and snow samples were collected and used for stratigraphic, isotopic, and chemical analyses. The firn-ice core and snow records were related to snow pit measurements at an event scale and to meteorological data and synoptic indices of atmospheric circulation at annual and seasonal scales. Linear relationships between the seasonal air temperature and seasonal isotopic composition in accumulated precipitation were established. Changes in the delta(18)O air temperature relationship, in major ion concentration and in the ratios between chemical species, were used to identify different sources of moisture and investigate changes in atmospheric circulation patterns. Precipitation over the central Tien Shan is characterized by the lowest ionic content among the Tien Shan glaciers and indicates its mainly marine origin. In seasons of minimum precipitation, autumn and winter, water vapor was derived from the arid and semiarid regions in central Eurasia and contributed annual maximal solute content to snow accumulation in Tien Shan. The lowest content of major ions was observed in spring and summer layers, which represent maximum seasonal accumulation when moisture originates over the Atlantic Ocean and Mediterranean and Black Seas.

Preliminary Results from the Chemical Records of an 80.4 M Ice Core Recovered from East Rongbuk Glacier, Qomolangma (Mount Everest), Himalaya

High-resolution chemical records from an 80.4 m ice core from the central Himalaya demonstrate climatic and environmental changes since 1844. The chronological net accumulation series shows a sharp decrease from the mid-1950s, which is coincident with the widely observed glacier retreat. A negative correlation is found between the ice-core delta(18)O record and the monsoon precipitation for Indian region 7. The temporal variation of the terrestrial ions (Ca2+ and Mg2+) is controlled by both the monsoon precipitation for Indian regions 3,7 and 8, located directly south and west of the Himalaya, and the dust-storm duration and frequency in the northern arid regions, such as the Taklimakan desert, China. The NH4+ profile is fairly flat until the 1940s, then substantially increases until the end of the 1980s, with a slight decrease during the 1990s which may reflect new agricultural practices. The SO42- and NO3- profiles show an apparent increasing trend, especially during the period 1940s-80s. Moreover, SO42- concentrations for the East Rongbuk Glacier core are roughly double that of the nearby Dasuopu core at Xixabangma, Himalaya, due to local human activity including that of climbing teams who use gasoline for cooking, energy and transport.

Ice Core Paleovolcanic Records from the St. Elias Mountains, Yukon, Canada

We previously reported a record of regionally significant volcanic eruptions in the North Pacific using an ice core from Eclipse Icefield (St. Elias Mountains, Yukon, Canada). The acquisition of two new ice cores from Eclipse Icefield, along with the previously available Eclipse Icefield and Mount Logan Northwest Col ice cores, allows us to extend our record of North Pacific volcanism to 550 years before present using a suite of four ice cores spanning an elevation range of 3 - 5 km. Comparison of volcanic sulfate flux records demonstrates that the results are highly reproducible, especially for the largest eruptions such as Katmai ( A. D. 1912). Correlation of volcanic sulfate signals with historically documented eruptions indicates that at least one-third of the eruptions recorded in St. Elias ice cores are from Alaskan and Kamchatkan volcanoes. Although there are several moderately large ( volcanic explosivity index (VEI) >= 4) eruptions recorded in only one core from Eclipse Icefield, the use of multiple cores provides signals in at least one core from all known VEI >= 4 eruptions in Alaska and Kamchatka since A. D. 1829. Tephrochronological evidence from the Eclipse ice cores documents eruptions in Alaska (Westdahl, Redoubt, Trident, and Katmai), Kamchatka (Avachinsky, Kliuchevoskoi, and Ksudach), and Iceland (Hekla). Several unidentified tephra-bearing horizons, with available geochemical evidence suggesting Alaskan and Kamchatkan sources, were also found. We present a reconstruction of annual volcanic sulfate loading for the North Pacific troposphere based on our ice core data, and we provide a detailed assessment of the atmospheric and climatic effects of the Katmai eruption.

The 1452 or 1453 A.D. Kuwae Eruption Signal Derived from Multiple Ice Core Records: Greatest Volcanic Sulfate Event of the Past 700 Years

We combined 33 ice core records, 13 from the Northern Hemisphere and 20 from the Southern Hemisphere, to determine the timing and magnitude of the great Kuwae eruption in the mid-15th century. We extracted volcanic deposition signals by applying a high-pass loess filter to the time series and examining peaks that exceed twice the 31 year running median absolute deviation. By accounting for the dating uncertainties associated with each record, these ice core records together reveal a large volcanogenic acid deposition event during 1453 - 1457 A. D. The results suggest only one major stratospheric injection from the Kuwae eruption and confirm previous findings that the Kuwae eruption took place in late 1452 or early 1453, which may serve as a reference to evaluate and improve the dating of ice core records. The average total sulfate deposition from the Kuwae eruption was 93 kg SO4/km(2) in Antarctica and 25 kg SO4/km(2) in Greenland. The deposition in Greenland was probably underestimated since it was the average value of only two northern Greenland sites with very low accumulation rates. After taking the spatial variation into consideration, the average Kuwae deposition in Greenland was estimated to be 45 kg SO4/km(2). By applying the same technique to the other major eruptions of the past 700 years our result suggests that the Kuwae eruption was the largest stratospheric sulfate event of that period, probably surpassing the total sulfate deposition of the Tambora eruption of 1815, which produced 59 kg SO4/km(2) in Antarctica and 50 kg SO4/km(2) in Greenland.

Tertiary Minette and Melanephelinite Dikes, Wasatch Plateau, Utah - Records of Mantle Heterogeneities and Changing Tectonics

A swarm of minette and melanephelinite dikes is exposed over 2500 km2 in and near the Wasatch Plateau, central Utah, along the western margin of the Colorado Plateaus in the transition zone with the Basin and Range province. To date, 110 vertical dikes in 25 dike sets have been recognized. Strikes shift from about N80-degrees-W for 24 Ma dikes, to about N60-degrees-W for 18 Ma, to due north for 8-7 m.y. These orientations are consistent with a shift from east-west Oligocene compression associated with subduction to east-west late Miocene crustal extension. Minettes are the most common rock type; mica-rich minette and mica-bearing melanephelinite occurs in 24 Ma dikes, whereas more ordinary minette is found in 8-7 Ma dikes. One melanephelinite dike is 18 Ma. These mafic alkaline rocks are transitional to one another in modal and major element composition but have distinctive trace element patterns and isotopic compositions; they appear to have crystallized from primitive magmas. Major, trace element, and Nd-Sr isotopic data indicate that melanephelinite, which has similarities to ocean island basalt, was derived from small degree melts of mantle with a chondritic Sm/Nd ratio probably located in the asthenosphere, but it is difficult to rule out a lithospheric source. In contrast, mica-bearing rocks (mica melanephelinite and both types of minette) are more potassic and have trace element patterns with strong Nb-Ta depletions and Sr-Nd isotopic compositions caused by involvement with a component from heterogeneously enriched lithospheric mantle with long-term enrichment of Rb or light rare earth elements (REE) (epsilon Nd as low as - 15 in minette). Light REE enrichment must have occurred anciently in the mid-Proterozoic when the lithosphere was formed and is not a result of Cenozoic subduction processes. After about 25 Ma, foundering of the subducting Farallon plate may have triggered upwelling of warm asthenospheric mantle to the base of the lithosphere. Melanephelinite magma may have separated from the asthenosphere and, while rising through the lithosphere, provided heat for lithospheric magma generation. Varying degrees of interaction between melanephelinite and small potassic melt fractions derived from the lithospheric mantle can explain the gradational character of the melanephelinite to minette suite.