Metaphrase: An Aid to the Clinical Conceptualization and Formalization of Patient Problems in Healthcare Enterprises

Patient descriptors, or “problems,” such as “brain metastases of melanoma” are an effective way for caregivers to describe patients. But most problems, e.g., “cubital tunnel syndrome” or “ulnar nerve compression,” found in problem lists in an Electronic Medical Record (EMR) are not comparable computationally – in general, a computer cannot determine whether they describe the same or a related problem, or whether the user would have preferred “ulnar nerve compression syndrome.” Metaphrase is a scalable, middleware component designed to be accessed from problemmanager applications in EMR systems. In response to caregivers' informal descriptors it suggests potentially equivalent, authoritative, and more formally comparable descriptors. Metaphrase contains a clinical subset of the 1997 UMLS Metathesaurus and some 10,000 “problems” from the Mayo Clinic and Harvard Beth Israel Hospital. Word and term completion, spelling correction, and semantic navigation, all combine to ease the burden of problem conceptualization, entry and formalization.

Interactive nature of climate change and aerosol forcing

The effect of changing cloud cover on climate, based on cloud-aerosol interactions, is one of the major unknowns for climate forcing and climate sensitivity. It has two components: (1) the impact of aerosols on clouds and climate due to in situ interactions (i.e., rapid response) and (2) the effect of aerosols on the cloud feedback that arises as climate changes-climate feedback response. We examine both effects utilizing the NASA Goddard Institute for Space Studies ModelE2 to assess the indirect effect, with both mass-based and microphysical aerosol schemes, in transient twentieth century simulations. We separate the rapid response and climate feedback effects by making simulations with a coupled version of the model as well as one with no sea surface temperature or sea ice response ("atmosphere-only" simulations). We show that the indirect effect of aerosols on temperature is altered by the climate feedbacks following the ocean response, and this change differs depending upon which aerosol model is employed. Overall, the effective radiative forcing (ERF) for the "direct effect" of aerosol-radiation interaction (ERFari) ranges between -0.2 and -0.6 W m^-2 for atmosphere-only experiments, while the total effective radiative forcing, including[C0]the indirect effect (ERFari+aci) varies between about -0.4 and -1.1 W m^-2 for atmosphere-only simulations; both ranges are in agreement with those given in Intergovernmental Panel on Climate Change (2013). Including the full feedback of the climate system lowers these ranges to -0.2 to -0.5 W m^-2 for ERFari and -0.3 to -0.74 W m^-2 for ERFari+aci. With both aerosol schemes, the climate change feedbacks have reduced the global average indirect radiative effect of atmospheric aerosols relative to what the emission changes would have produced, at least partially due to its effect on tropical upper tropospheric clouds.

Glacial-interglacial changes in moisture sources for greenland: influences on the ice core record of climate

Large, abrupt shifts in the (l8)O/(16)O ratio found in Greenland ice must reflect real features of the climate system variability. These isotopic shifts can be viewed as a result of air temperature fluctuations, but determination of the cause of the changes-the most crucial issue for future climate concerns-requires a detailed understanding of the controls on isotopes in precipitation. Results from general circulation model experiments suggest that the sources of Greenland precipitation varied with different climate states, allowing dynamic atmospheric mechanisms for influencing the ice core isotope shifts.

Climate response times: dependence on climate sensitivity and ocean mixing

The factors that determine climate response times were investigated with simple models and scaling statements. The response times are particularly sensitive to (i) the amount that the climate response is amplified by feedbacks and (ii) the representation of ocean mixing. If equilibrium climate sensitivity is 3 degrees C or greater for a doubling of the carbon dioxide concentration, then most of the expected warming attributable to trace gases added to the atmosphere by man probably has not yet occurred. This yet to be realized warming calls into question a policy of "wait and see" regarding the issue of how to deal with increasing atmospheric carbon dioxide and other trace gases.

Climate impact of increasing atmospheric carbon dioxide

The global temperature rose by 0.2 degrees C between the middle 1960's and 1980, yielding a warming of 0.4 degrees C in the past century. This temperature increase is consistent with the calculated greenhouse effect due to measured increases of atmospheric carbon dioxide. Variations of volcanic aerosols and possibly solar luminosity appear to be primary causes of observed fluctuations about the mean trend of increasing temperature. It is shown that the anthropogenic carbon dioxide warming should emerge from the noise level of natural climate variability by the end of the century, and there is a high probability of warming in the 1980's. Potential effects on climate in the 21st century include the creation of drought-prone regions in North America and central Asia as part of a shifting of climatic zones, erosion of the West Antarctic ice sheet with a consequent worldwide rise in sea level, and opening of the fabled Northwest Passage.

The Sun's role in climate variations

Is the Sun the controller of climate changes, only the instigator of changes that are mostly forced by the system feedbacks, or simply a convenient scapegoat for climate variations lacking any other obvious cause? This question is addressed for suggested solar forcing mechanisms operating on time scales from billions of years to decades. Each mechanism fails to generate the expected climate response in important respects, although some relations are found. The magnitude of the system feedbacks or variability appears as large or larger than that of the solar forcing, making the Sun's true role ambiguous. As the Sun provides an explicit external forcing, a better understanding of its cause and effect in climate change could help us evaluate the importance of other climate forcings (such as past and future greenhouse gas changes).

Solar forcing of regional climate change during the Maunder Minimum

We examine the climate response to solar irradiance changes between the late 17th-century Maunder Minimum and the late 18th century. Global average temperature changes are small (about 0.3 degrees to 0.4 degrees C) in both a climate model and empirical reconstructions. However, regional temperature changes are quite large. In the model, these occur primarily through a forced shift toward the low index state of the Arctic Oscillation/North Atlantic Oscillation as solar irradiance decreases. This leads to colder temperatures over the Northern Hemisphere continents, especially in winter (1 degrees to 2 degrees C), in agreement with historical records and proxy data for surface temperatures.

Solar cycle variability, ozone, and climate

Results from a global climate model including an interactive parameterization of stratospheric chemistry show how upper stratospheric ozone changes may amplify observed, 11-year solar cycle irradiance changes to affect climate. In the model, circulation changes initially induced in the stratosphere subsequently penetrate into the troposphere, demonstrating the importance of the dynamical coupling between the stratosphere and troposphere. The model reproduces many observed 11-year oscillations, including the relatively long record of geopotential height variations; hence, it implies that these oscillations are likely driven, at least in part, by solar variability.

Complexity and climate

The climate that we experience results from both ordered forcing and chaotic behavior; the result is a system with characteristics of each. In forecasting prospective climate changes for the next century, the focus has been on the ordered system's responses to anthropogenic forcing. The chaotic component may be much harder to predict, but at this point it is not known how important it will be.

Metaphrase: an aid to the clinical conceptualization and formalization of patient problems in healthcare enterprises

Patient descriptors, or "problems," such as "brain metastases of melanoma" are an effective way for caregivers to describe patients. But most problems, e.g., "cubital tunnel syndrome" or "ulnar nerve compression," found in problem lists in an Electronic Medical Record (EMR) are not comparable computationally--in general, a computer cannot determine whether they describe the same or a related problem, or whether the user would have preferred "ulnar nerve compression syndrome." Metaphrase is a scalable, middleware component designed to be accessed from problem-manager applications in EMR systems. In response to caregivers' informal descriptors it suggests potentially equivalent, authoritative, and more formally comparable descriptors. Metaphrase contains a clinical subset of the 1997 UMLS Metathesaurus and some 10,000 "problems" from the Mayo Clinic and Harvard Beth Israel Hospital. Word and term completion, spelling correction, and semantic navigation, all combine to ease the burden of problem conceptualization, entry and formalization.

Electronic communication and collaboration in a health care practice

Using cognitive evaluation techniques, this study examines the effects of an electronic patient record and electronic mail on the interactions of health care providers. We find that the least structured communication methods are also the most heavily used: face-to-face, telephone, and electronic mail. Positive benefits of electronically-mediated interactions include improving communication, collaboration, and access to information to support decision-making. Negative factors include the potential for overloading clinicians with unwanted or unnecessary communications.

Nationwide telecare for diabetics: a pilot implementation of the HOLON architecture

This paper presents results from a demonstration project of nationwide exchange of health data for the home care of diabetic patients. A consortium of industry, academic, and health care partners has developed reusable middleware components integrated using the HOLON architecture. Engineering approaches for multi-organization systems development, lessons learned in developing layered object-oriented systems, security and confidentiality considerations, and functionality for nationwide telemedicine applications are discussed.

THE ROLE OF MOISTURE TRANSPORT BETWEEN GROUND AND ATMOSPHERE IN GLOBAL CHANGE

▪ Abstract  Projections of the effect of climate change on future water availability are examined by reviewing the formulations used to calculate moisture transport between the ground and the atmosphere. General circulation models and climate change impact models have substantially different formulations for evapotranspiration, so their projections of future water availability often disagree, even though they use the same temperature and precipitation forecasts. General circulation models forecast little change in tropical and subtropical water availability, while impact models show severe water and agricultural shortages. A comparison of observations and modeling techniques shows that the parameterizations in general circulation models likely lead to an underestimate of the impacts of global warming on soil moisture and vegetation. Such errors would crucially affect the temperature and precipitation forecasts used in impact models. Some impact model evaporation formulations are probably more appropriate than those in general circulation models, but important questions remain. More observations are needed, especially in the vicinity of forests, to determine appropriate parameterizations.

A WWW implementation of national recommendations for protecting electronic health information

In March of 1997, the National Research Council (NRC) of the National Academy of Sciences issued the report, "For the Record: Protecting Electronic Health Information." Concluding that the current practices at the majority of health care facilities in the United States are insufficient, the Council delineated both technical and organizational approaches to protecting electronic health information. The Beth Israel Deaconess Medical Center recently implemented a proof-of-concept, Web-based, cross-institutional medical record, CareWeb, which incorporates the NRC security and confidentiality recommendations. We report on our WWW implementation of the NRC recommendations and an initial evaluation of the balance between ease of use and confidentiality.

Using HL7 and the World Wide Web for unifying patient data from remote databases

W3-EMRS is an architecture designed to access clinical data from remote heterogeneous electronic medical record system (EMRS) databases. We describe the technologies used in an experimental implementation of W3-EMRS that concurrently collects data from several sources and presents them in an integrated set of views. After describing some of the organizational constraints, the architectural decision, implementation methodology, and operation of the completed project are discussed.

Sharing electronic medical records across multiple heterogeneous and competing institutions

Most early reports of implemented World-Wide Web (W3) medical record systems describe single institution architectures. We describe W3-EMRS, a multi-institutional architecture, and its implementation. Thorny problems in data sharing underlined by the W3-EMRS project are reviewed.

Protection of confidentiality in the computer-based patient record

To evaluate the confidentiality of the patients' data in the electronic patient records designed by members of the Center for Clinical Computing in Boston, we examined the accessibility of the computer-stored medical records of two groups of patients at Boston's Beth Israel Hospital: celebrities, hospital employees, and their relatives (VIPs) and other patients (non-VIPs). We studied how often authorized clinicians gained access to computer-stored data on the two types of patients and whether look-up patterns differed if the data concerned a VIP. Our results suggest that the measures used to maintain data confidentiality at Beth Israel Hospital are adequate.

Patient entries in the electronic medical record: an interactive interview used in primary care

We describe the development, implementation, and use of a computer-administered patient interview, the Health History Interview, by over 300 new patients in a primary care practice at Boston's Beth Israel Hospital. The interview has been well accepted by patients and rated positively by providers. It electronically captures clinical information directly from patients for use during their initial encounter with a provider. It facilitates aggregate analysis of clinical data for quality improvement efforts, such as aiming preventive medicine interventions at identified problem areas within the clinic. Expectations management has been an important task throughout the project. Increasing use of the interview beyond the 30-40% of new patients who have taken it will require greater communication with patients, greater convenience to patients and providers, and more evidence of the clinical, administrative, and research benefits of the technique. Most important, full implementation will require fundamental changes in physician practice habits and patterns of communication between patients and the health care system, as well as clearly demonstrated cost-benefit improvements through the use of these tools.

Computer-based support for clinical decision making

Although computers are now commonly used for financial purposes in hospitals and physicians' offices, most physicians do not routinely use them in patient care. And in hospitals where laboratory data are provided on computer terminals, the displays are often difficult to use and programs that offer assistance in interpreting the data are usually unavailable. We have developed decision support programs that are widely used with the clinical computing system at our hospital. This paper describes the programs and how the clinicians use them.