The Piedra Chamana fossil woods and leaves: a record of the vegetation and palaeoenvironment of the Neotropics during the late middle Eocene.

BACKGROUND AND AIMS: The Piedra Chamana fossil forest in northern Peru is an assemblage of angiosperm woods and leaves preserved in volcaniclastic rocks dated to 39 Mya (late Middle Eocene). We analysed the anatomical and morphological features of the fossils to reconstruct the palaeoenvironment during this time of global warmth, taking advantage of the co-occurrence of woods and leaves to compare different proxies and analytical approaches. METHODS: Wood characters analysed include vessel-related functional traits, traits linked to Baileyan trends, and quantitative features such as vessel diameter and density. Diameter-distribution and diameter and position plots are used to represent vessel diameter and arrangement. Leaf margin and area analysis provides additional climate estimates. KEY RESULTS: The fossil woods show many similarities with modern tropical-forest woods and tropical fossil-wood assemblages; closest correspondence within the Neotropics is to semi-deciduous lowland tropical forest with moderate precipitation (~1000-1200 mm). Features unusual for the modern South American tropics are mainly vessel-related characters (semi-ring porosity, grouped vessels, helical vessel thickenings, short vessel elements) linked to water stress or seasonal water availability. Leaf analysis indicates mean annual temperature of 31 °C (n = 19, 100 % entire-margined) and mean annual precipitation of 1290 mm (n = 22, predominantly microphylls and notophylls). CONCLUSIONS: The palaeovegetation was clearly lowland tropical forest with a dry aspect, but anomalous aspects of the wood anatomy are consistent with the high temperatures indicated by the leaves and are probably explained by differences in seasonality and water stress compared to the present-day Neotropics. A close modern analogue may be in very seasonal regions of Asia. Pronounced monsoonal (summer-rain) conditions may relate to a location (palaeolatitude of 13°S) outside the near-equatorial tropics.

The Evolving Role of Medical Scribe: Variation and Implications for Organizational Effectiveness and Safety.

Increasing use of medical scribes is an unintended consequence of electronic health record adoption in the U.S. The role of scribe is not universally defined, leading to variations in scribe training and operations, as well as questions about scribe efficiency, effectiveness, and safety. Studies published since 2009 have primarily focused on the financial aspects of scribe use, but no published studies have taken an organizational view of this phenomenon. This paper describes stakeholder perspectives on scribes working in outpatient settings within an urban tertiary academic medical center. It places factors associated with of scribe systems within an eight-dimension sociotechnical framework for evaluating health information technology, and discusses key aspects of those perspectives.

Use of Simulation Based on an Electronic Health Records Environment to Evaluate the Structure and Accuracy of Notes Generated by Medical Scribes: Proof-of-Concept Study.

BACKGROUND: The increasing adoption of electronic health records (EHRs) has been associated with a number of unintended negative consequences with provider efficiency and job satisfaction. To address this, there has been a dramatic increase in the use of medical scribes to perform many of the required EHR functions. Despite this rapid growth, little has been published on the training or assessment tools to appraise the safety and efficacy of scribe-related EHR activities. Given the number of reports documenting that other professional groups suffer from a number of performance errors in EHR interface and data gathering, scribes likely face similar challenges. This highlights the need for new assessment tools for medical scribes. OBJECTIVE: The objective of this study was to develop a virtual video-based simulation to demonstrate and quantify the variability and accuracy of scribes' transcribed notes in the EHR. METHODS: From a pool of 8 scribes in one department, a total of 5 female scribes, intent on pursuing careers in health care, with at least 6 months of experience were recruited for our simulation study. We created three simulated patient-provider scenarios. Each scenario contained a corresponding medical record in our simulation instance of our EHR. For each scenario, we video-recorded a standardized patient-provider encounter. Five scribes with at least 6 months of experience both with our EHR and in the specialty of the simulated cases were recruited. Each scribe watched the simulated encounter and transcribed notes into a simulated EHR environment. Transcribed notes were evaluated for interscribe variability and compared with a gold standard for accuracy. RESULTS: All scribes completed all simulated cases. There was significant interscribe variability in note structure and content. Overall, only 26% of all data elements were unique to the scribe writing them. The term data element was used to define the individual pieces of data that scribes perceived from the simulation. Note length was determined by counting the number of words varied by 31%, 37%, and 57% between longest and shortest note between the three cases, and word economy ranged between 23% and 71%. Overall, there was a wide inter- and intrascribe variation in accuracy for each section of the notes with ranges from 50% to 76%, resulting in an overall positive predictive value for each note between 38% and 81%. CONCLUSIONS: We created a high-fidelity, video-based EHR simulation, capable of assessing multiple performance indicators in medical scribes. In this cohort, we demonstrate significant variability both in terms of structure and accuracy in clinical documentation. This form of simulation can provide a valuable tool for future development of scribe curriculum and assessment of competency.

A Mixed Methods Task Analysis of the Implementation and Validation of EHR-Based Clinical Quality Measures.

Clinical quality measures (CQMs) are important tools for the assessment and improvement of health care quality. Federal requirements initially set forth in the American Recovery and Reinvestment Act, and advanced in subsequent stages of the requirements, codified electronic health record (EHR)-based CQM reporting, and have made automated CQM implementation a priority amongst the clinical and informatics communities. Nevertheless, the processes surrounding CQM implementation and validation remain complex, time-consuming, and largely undefined. We collected issue-tracking data during the course of an agile and rigorous collaborative project to build an analytics platform for the Knight Cardiovascular Institute at OHSU, with nine heart failure CQMs defined by the American College of Cardiology (ACC) as an exemplar. Using a mixed methods approach we provide an overview of our CQM implementation and validation process, identify major roadblocks and bottlenecks, and make recommendations for other professionals working in the area of health care quality assessment and improvement.

Using Simulations to Improve Electronic Health Record Use, Clinician Training and Patient Safety: Recommendations From A Consensus Conference.

A group of informatics experts in simulation, biomedical informatics, patient safety, medical education, and human factors gathered at Corbett, Oregon on April 30 and May 1, 2015. Their objective: to create a consensus statement on best practices for the use of electronic health record (EHR) simulations in education and training, to improve patient safety, and to outline a strategy for future EHR simulation work. A qualitative approach was utilized to analyze data from the conference and generate recommendations in five major categories: (1) Safety, (2) Education and Training, (3) People and Organizations, (4) Usability and Design, and (5) Sociotechnical Aspects.

Accelerating anthropogenic land surface change and the status of Pleistocene drumlins in New England.

Drumlins are glacially derived landforms that are prominent in the landscape over much of southern New England. We carried out a comprehensive ground-based survey in a three-town study area in eastern Massachusetts with the goals of establishing the extent to drumlins have been altered and assessing the associated environmental consequences and probable driving factors. Results show that many drumlins have been significantly altered through levelling and truncation (creation of steep cut and fill slopes), with projects involving movement of 1-1.5×10(6) m(3) of earth materials not now uncommon. Stormwater and wetlands infractions were documented at all the larger excavation sites and resulted in enforcement actions and fines in many cases; the broader environmental consequences of the loss/alteration of these forested uplands are harder to establish. The excavations are significant in terms of materials cycling: the movement of earth materials, when considered regionally, greatly exceeds natural denudation processes and is also greater than during other periods of high anthropogenic denudation. Our findings suggest that the region's glacial landscapes are at risk given current development patterns. The accelerating rate of land-surface change is undoubtedly also generalizable to other fast-developing regions of the United States. The landform alterations documented are part of a changing pattern of land use and vegetation cover since the Colonial era and are linked to shortages of land for development, current development and building practices, and lack of explicit rationales for preservation of the region's geoheritage.