Storm types in India: linking rainfall duration, spatial extent and intensity.

We examine wet events (WEs) defined from an hourly rainfall dataset based on 64 gauged observations across India (1969-2016). More than 90% of the WEs (accounting for nearly 60% of total rainfall) are found to last less than or equal to 5 h. WEs are then clustered into six canonical local-scale storm profiles (CanWE). The most frequent canonical type (CanWE#1 and #2) are associated with very short and nominal rainfall. The remaining canonical WEs can be grouped into two broad families: (i) CanWE#3 and #5 with short (usually less than or equal to 3-4 h), but very intense rainfall strongly phase-locked onto the diurnal cycle (initiation peaks in mid-afternoon) and probably related to isolated thunderstorms or small mesoscale convective clusters (MCS), and (ii) CanWE#4 and #6 with longer and lighter rainfall in mean (but not necessarily for their maximum) and more independent of the diurnal cycle, thus probably related to larger MCSs or tropical lows. The spatial extent of the total rainfall received during each CanWE, as shown by IMERG gridded rainfall, is indeed smaller for CanWE#3 and #5 than for CanWE#4 and especially #6. Most of the annual maximum 1 hour rainfalls occur during CanWE#5. Long-term trend analysis of the June-September canonical WEs across boreal monsoonal India reveals an increase in the relative frequency of the convective storm types CanWE#3 and #5 in recent years, as expected from global warming and thermodynamic considerations. This article is part of a discussion meeting issue 'Intensification of short-duration rainfall extremes and implications for flash flood risks'.

COVID-19 and telehealth, education, and research adaptations.

For decades, there have been government funded services to provide healthcare telephonically to remote sites both on the earth and in the air. This capability has evolved into what we now know as telehealth. The use of telehealth dramatically accelerated as a result of concerns for patient and healthcare provider safety during the SARS-CoV2 pandemic. Similarly, concerns regarding transmission of infection have required medical schools to provide robust, easily accessible virtual education options. At short notice, faculties have had to develop new telehealth focused curriculum components. However, telehealth, online education, and internet enabled research should not be simply a new way to do traditional jobs but rather, an opportunity to take advantage of how technology can best be used to develop new and better ways to provide care, educate health care providers, and support research.

Extremes in water availability and suicide: Evidence from a nationally representative sample of rural Indian adults.

BACKGROUND: Extremes in water availability, either exceptionally wet or dry conditions, can damage crops and may detrimentally affect the livelihood and well-being of people engaged in agriculture. We estimated the effect of water availability on suicide in rural India, a context where the majority of households are dependent upon agriculture. METHODS: We used data from a nationally representative sample of 8.5 million people who were monitored for causes of death from 2001 to 2013. Water availability was measured with high-resolution precipitation and temperature data (i.e., the Standardized Precipitation Evapotranspiration Index). We used a fixed effects approach that modeled changes in water availability within districts (n = 569) over time (n = 13 years) to estimate the impact on suicide deaths. We restricted our analysis to rural areas and to deaths occurring during the growing season (June-March) among adults aged 15 or older, and controlled for sex, age, region, and year. We used Poisson regression with standard errors clustered at the district level and total deaths as the offset. RESULTS: There were 9456 suicides and 249,786 total deaths in our study population between 2001 and 2013. Compared to normal growing seasons, the percent of deaths due to suicide increased by 18.7% during extremely wet growing seasons (95% CI: 6.2, 31.2) and by 3.6% during extremely dry growing seasons (95% CI: -17.9, 25.0). We found that effects varied by age. CONCLUSIONS: We found extremes is water availability associated with an increase in suicide. Abnormally wet growing conditions may play an important, yet overlooked, role in suicide among rural Indian adults.

An exploratory study of networks constructed using access data from an electronic health record.

Network analysis may be a powerful tool for studying interprofessional practice. Using electronic health record data and social network analysis, the network of healthcare professionals involved in colorectal cancer care at a large, urban academic medical center were mapped and studied. A total of 100 surgical colorectal cancer patients receiving treatment in 2013 and 2014 were selected at random. We used detailed access logs for the EHR to map the network of all healthcare professionals for each patient, including inpatient and outpatient settings. Approximately 2.45 million records of access logs from more than 6,800 unique users, representing over 150 roles or occupations were analyzed. Across all networks, professionals were connected to an average of 5.8 other professionals, but some were rarely connected with others while over 20 were very highly connected (> 100 other professionals). Housestaff, attending physicians, and nurses played central roles in the global network with a high number of inter- and intra-professional connections. Clusters of professionals with frequent interaction were demonstrated but, based on the size and complexity of the network, serendipitous interactions were unlikely. Settings for care seemed to influence these clusters. Patient-centric care networks were similar to the global network with some potentially important differences. Access-log information from electronic health records can be an important source of information about relationships between healthcare professionals. Findings from analyses such as this one may help define the state of current networks and potential targets for interventions to improve the quality of care.

A prominent pattern of year-to-year variability in Indian Summer Monsoon Rainfall.

The dominant patterns of Indian Summer Monsoon Rainfall (ISMR) and their relationships with the sea surface temperature and 850-hPa wind fields are examined using gridded datasets from 1900 on. The two leading empirical orthogonal functions (EOFs) of ISMR over India are used as basis functions for elucidating these relationships. EOF1 is highly correlated with all India rainfall and El Niño-Southern Oscillation indices. EOF2 involves rainfall anomalies of opposing polarity over the Gangetic Plain and peninsular India. The spatial pattern of the trends in ISMR from 1950 on shows drying over the Gangetic Plain projects onto EOF2, with an expansion coefficient that exhibits a pronounced trend during this period. EOF2 is coupled with the dominant pattern of sea surface temperature variability over the Indian Ocean sector, which involves in-phase fluctuations over the Arabian Sea, the Bay of Bengal, and the South China Sea, and it is correlated with the previous winter's El Niño-Southern Oscillation indices. The circulation anomalies observed in association with fluctuations in the time-varying indices of EOF1 and EOF2 both involve distortions of the low-level monsoon flow. EOF1 in its positive polarity represents a southward deflection of moist, westerly monsoon flow from the Arabian Sea across India, resulting in a smaller flux of moisture to the Himalayas. EOF2 in its positive polarity represents a weakening of the monsoon trough over northeastern India and the westerly monsoon flow across southern India, reminiscent of the circulation anomalies observed during break periods within the monsoon season.

Drought Atlas of India, 1901-2020.

India has been considerably affected by droughts in the recent past. Despite the considerable impacts of droughts on agriculture and water resources, long-term datasets to examine droughts and their consequences at appropriate spatial and temporal scales have been lacking in India. Datasets that provide drought information are mostly available for a short period and at coarser resolutions, therefore, these do not comprehend the information regarding the major droughts that occurred in the distant past at administrative scales of decision-making. To fill this critical gap, we developed the high-resolution (0.05°) and long-term monthly precipitation and temperature datasets for the 1901-2021 period. We used long-term high-resolution precipitation and temperature to estimate droughts using standardized precipitation and evapotranspiration index (SPEI). As SPEI considers the role of air temperature in drought estimation, it can be used to examine meteorological, agricultural, and hydrological droughts. Using high-resolution SPEI, we developed drought atlas for India (1901-2020) that can provide comprehensive information on drought occurrence, impacts, and risks in India.

Patient care in complex Sociotechnological ecosystems and learning health systems.

The learning health system (LHS) model was proposed to provide real-time, bi-directional flow of learning using data captured in health information technology systems to deliver rapid learning in healthcare delivery. As highlighted by the landmark National Academy of Medicine report "Crossing the Quality Chasm," the U.S. healthcare delivery industry represents complex adaptive systems, and there is an urgent need to develop innovative methods to identify efficient team structures by harnessing real-world care delivery data found in the electronic health record (EHR). We offer a discussion surrounding the complexities of team communication and how solutions may be guided by theories such as the Multiteam System (MTS) framework and the Multitheoretical Multilevel Framework of Communication Networks. To advance healthcare delivery science and promote LHSs, our team has been building a new line of research using EHR data to study MTS in the complex real world of cancer care delivery. We are developing new network metrics to study MTSs and will be analyzing the impact of EHR communication network structures on patient outcomes. As this research leads to patient care delivery interventions/tools, healthcare leaders and healthcare professionals can effectively use health IT data to implement the most evidence-based collaboration approaches in order to achieve the optimal LHS and patient outcomes.

Increased hydropower but with an elevated risk of reservoir operations in India under the warming climate.

Hydropower is a significant contributor to clean global electricity generation; therefore, it plays a crucial role in climate change mitigation. Notwithstanding major hydropower dams in India are in diverse climatic regions and exposed to risks because of the warming climate, potential changes in hydroclimate remain largely unexplored. Using observations and climate projections, we demonstrate the hydroclimatic changes in the upstream catchments and their implications for the hydropower generation of 46 major hydropower dams in India. A warmer (up to 5.0°C) and wetter projected climate with a substantial increase (5.0-33%) in precipitation will lead to an increased (7-70%) inflow to reservoirs of major dams. Increased inflow will enhance (9-36%) the hydropower production for most dams in the future, with a more prominent rise in central India dams. A simultaneous rise in extreme inflow and high reservoir storage conditions is projected under future climate for most dams. However, future climate changes project a favorable hydroclimate for hydropower production, with the associated risks related to extremes.

Hydrological model-based streamflow reconstruction for Indian sub-continental river basins, 1951-2021.

Streamflow is a vital component of the global water cycle. Long-term streamflow observations are required for water resources planning and management, hydroclimatic extremes analysis, and ecological assessment. However, long-term streamflow observations for the Indian-Subcontinental (ISC) river basins are lacking. Using meteorological observations, state-of-the-art hydrological model, and river routing model, we developed hydrological model-simulated monthly streamflow from 1951-2021 for the ISC river basins. We used high-resolution vector-based routing model (mizuRoute) to generate streamflow at 9579 stream reaches in the sub-continental river basins. The model-simulated streamflow showed good performance against the observed flow with coefficient of determination (R2) and Nash-Sutcliffe efficiency (NSE) above 0.70 for more than 60% of the gauge stations. The dataset was used to examine the variability in low, average, and high flow across the streams. Long-term changes in streamflow showed a significant decline in flow in the Ganga basin while an increase in the semi-arid western India and Indus basin. Long-term streamflow can be used for planning water management and climate change adaptation in the Indian sub-continent.

Rigorous and rapid evidence assessment in digital health with the evidence DEFINED framework.

Dozens of frameworks have been proposed to assess evidence for digital health interventions (DHIs), but existing frameworks may not facilitate DHI evidence reviews that meet the needs of stakeholder organizations including payers, health systems, trade organizations, and others. These organizations may benefit from a DHI assessment framework that is both rigorous and rapid. Here we propose a framework to assess Evidence in Digital health for EFfectiveness of INterventions with Evaluative Depth (Evidence DEFINED). Designed for real-world use, the Evidence DEFINED Quick Start Guide may help streamline DHI assessment. A checklist is provided summarizing high-priority evidence considerations in digital health. Evidence-to-recommendation guidelines are proposed, specifying degrees of adoption that may be appropriate for a range of evidence quality levels. Evidence DEFINED differs from prior frameworks in its inclusion of unique elements designed for rigor and speed. Rigor is increased by addressing three gaps in prior frameworks. First, prior frameworks are not adapted adequately to address evidence considerations that are unique to digital health. Second, prior frameworks do not specify evidence quality criteria requiring increased vigilance for DHIs in the current regulatory context. Third, extant frameworks rarely leverage established, robust methodologies that were developed for non-digital interventions. Speed is achieved in the Evidence DEFINED Framework through screening optimization and deprioritization of steps that may have limited value. The primary goals of Evidence DEFINED are to a) facilitate standardized, rapid, rigorous DHI evidence assessment in organizations and b) guide digital health solutions providers who wish to generate evidence that drives DHI adoption.

Climate warming and summer monsoon breaks drive compound dry and hot extremes in India.

Considering the severe impacts of compound dry and hot extremes, we examine the primary drivers of CDHEs during the summer monsoon in India. Using ERA5 reanalysis, we show that most of the CDHEs in India occur during the droughts caused by the summer monsoon rainfall deficit. Despite a decline in the frequency of summer monsoon droughts in recent decades, increased CDHEs are mainly driven by warming and dry spells during the summer monsoon particularly in the Northeast, central northeast, and west central regions. A strong land-atmospheric coupling during droughts in the summer monsoon season leads to frequent CDHEs in the Northwest and southern peninsular regions. Furthermore, regional variations in land-atmospheric coupling cause substantial differences in the CDHE occurrence in different parts of the country. Summer monsoon rainfall variability and increased warming can pose a greater risk of compound dry and hot extremes with severe impacts on various sectors in India.

Factors That Influence Clinician Experience with Electronic Health Records.

Objectives: To report quantitative and qualitative analyses of features, functionalities, organizational, training, clinical specialties, and other factors that impact electronic health record (EHR) experience based on a survey by two large healthcare systems. Materials and Methods: A total of 816 clinicians-352 (43 percent) physicians, 96 (12 percent) residents/fellows, 177 (22 percent) nurses, 96 (12 percent) advanced practice providers, and 95 (12 percent) allied health professionals-completed surveys on different EHRs. Responses were analyzed for quantitative and qualitative factors. The measured outcome was calculated as a net EHR experience. Results: Net EHR experience represents overall satisfaction that clinicians report with the EHR and its usability. EHR experience for Virginia Commonwealth University Medical Center and University of Chicago Medicine was low. There were noticeable differences in physician and nursing experiences with EHRs at both universities. EHR personalization, years of practice, impact on efficiency, quality of care, and satisfaction with EHR training contributed significantly to the net EHR experience. Satisfaction of certain specialty practitioners such as endocrinology, family medicine, infectious disease, nephrology, neurology, and pulmonology was noted to be especially low. Ability to use a split-screen function to view labs, follow-up training from other providers rather than vendors, reduced documentation time burden, fewer click boxes, more customizable order sets, improved messaging, e-prescribing, and improved integration were the most common desired EHR improvements requested on qualitative analysis. Discussion: EHR experience was low regardless of the system and may be improved by better EHR training, increased utilization of personalization tools, reduced documentation burden, and enhanced EHR design and functionality. There was a difference between provider and nursing experiences with the EHR. Conclusion: Designing better EHR training, increasing utilization of personalization tools, enhancing functionality, and decreasing documentation burden may lead to a better EHR experience.

Runoff sensitivity of Indian sub-continental river basins.

Understanding the sensitivity of water availability in the current and future climate in the Indian sub-continent is vital for food and water security. Using the Variable Infiltration Capacity (VIC) model and Budyko's framework with two observational datasets, we estimated water budget and mean annual runoff sensitivity to precipitation and potential evapotranspiration (PET) over 18 major river basins and 222 sub-basins in the Indian sub-continent. The river basins located in the north experienced a decline in mean annual precipitation while the basins in the south witnessed an increase in mean annual precipitation. Declined precipitation and increased PET resulted in a decrease in mean annual runoff in Brahmaputra, Ganga, and Indus basins during 1980-2014. On the other hand, mean annual runoff has increased in Sabarmati, South Coast, Subernarekha, Tapi, Mahanadi, East coast, Cauvery, and Brahmani river basins. Mean annual AET estimated using the Budyko's framework was underestimated while mean annual total runoff was overestimated for the majority of the basins in comparison to the estimates from the VIC model. Moreover, the Budyko's framework with both observational datasets underestimated runoff sensitivity to the changes in precipitation and PET in comparison to the VIC model. Runoff is more sensitive to change in precipitation than PET for the majority of the river basins highlighting the importance of changes in precipitation for water availability in the Indian sub-continent. The VIC model simulated runoff and evapotranspiration are in better agreement with the observations in comparison to the estimates from the Budyko's framework. However, a large uncertainty was found in water budget and runoff sensitivity estimated using the VIC and Budyko's models, which highlights the importance of considering multiple models for estimation of the water budget and runoff sensitivity in the sub-continental river basins.

Changes in Physician Telemedicine Use during COVID-19: Effects of Practice Setting, Demographics, Training, and Organizational Policies.

Telemedicine use increased during the COVID-19 pandemic, but uptake was uneven and future use is uncertain. This study, then, examined the ability of personal and environmental variables to predict telemedicine adoption during the COVID-19 pandemic. A total of 230 physicians practicing in the U.S. completed questions concerning personal and environmental characteristics, as well as telemedicine use at three time points: pre-pandemic, during the pandemic, and anticipated future use. Associations between use and characteristics were determined to identify factors important for telemedicine use. Physicians reported that telemedicine accounted for 3.72% of clinical work prior to the pandemic, 46.03% during the pandemic, and predicted 25.44% after the pandemic ends. Physicians within hospitals reported less increase in telemedicine use during the pandemic than within group practice (p = 0.016) and less increase in use at hospitals compared to academic medical centers (p = 0.027) and group practice (p = 0.008). Greater telemedicine use was associated with more years in practice (p = 0.009), supportive organizational policies (p = 0.001), organizational encouragement (p = 0.003), expectations of greater patient volume (p = 0.003), and perceived higher quality of patient care (p = 0.032). Characteristics such as gender, number of physicians, and level of telemedicine training were not significant predictors. Organizations interested in supporting physicians to adopt telemedicine should encourage its use and create policies supporting its use. More senior physicians had a greater degree of telemedicine uptake, while training programs did not predict use, suggesting that efforts to develop telemedicine competency in younger physicians may be ineffective and should be re-examined.

Global distribution, trends, and drivers of flash drought occurrence.

Flash drought is characterized by a period of rapid drought intensification with impacts on agriculture, water resources, ecosystems, and the human environment. Addressing these challenges requires a fundamental understanding of flash drought occurrence. This study identifies global hotspots for flash drought from 1980-2015 via anomalies in evaporative stress and the standardized evaporative stress ratio. Flash drought hotspots exist over Brazil, the Sahel, the Great Rift Valley, and India, with notable local hotspots over the central United States, southwestern Russia, and northeastern China. Six of the fifteen study regions experienced a statistically significant increase in flash drought during 1980-2015. In contrast, three study regions witnessed a significant decline in flash drought frequency. Finally, the results illustrate that multiple pathways of research are needed to further our understanding of the regional drivers of flash drought and the complex interactions between flash drought and socioeconomic impacts.

Telerounding: A scoping review and implications for future healthcare practice.

Introduction: Telerounding is slated to become an important avenue for future healthcare practice. As utilization of telerounding is increasing, a review of the literature is necessary to distill themes and identify critical considerations for the implementation of telerounding. We provide evidence of the utility of telerounding and considerations to support its implementation in future healthcare practice based on a scoping review. Method: We collected articles from nine scientific databases from the earliest dated available articles to August 2020. We identified whether each article centered on telerounding policies, regulations, or practice. We also organized information from each article and sorted themes into four categories: sample characteristics, technology utilized, study constructs, and research outcomes. Results: We identified 21 articles related to telerounding that fit our criteria. All articles emphasized telerounding practice. Most articles reported data collected from surgical wards, had adult samples, and utilized robotic telerounding systems. Most articles reported null effects or positive effects on their measured variables. Discussion: Providers and patients can benefit from the effective implementation of telerounding. Telerounding can support patient care by reducing travel expenses and opportunities for infection. Evidence suggests that telerounding can reduce patient length of stay. Patients and providers are willing to utilize telerounding, but patient willingness is influenced by age and education. Telerounding does not appear to negatively impact satisfaction or patient care. Organizations seeking to implement telerounding systems must consider education for their providers, logistics associated with hardware and software, scheduling, and characteristics of the organizational context that can support telerounding. Considerations provided in this article can mitigate difficulties associated with the implementation of telerounding.

Bias-corrected climate projections for South Asia from Coupled Model Intercomparison Project-6.

Climate change is likely to pose enormous challenges for agriculture, water resources, infrastructure, and livelihood of millions of people living in South Asia. Here, we develop daily bias-corrected data of precipitation, maximum and minimum temperatures at 0.25° spatial resolution for South Asia (India, Pakistan, Bangladesh, Nepal, Bhutan, and Sri Lanka) and 18 river basins located in the Indian sub-continent. The bias-corrected dataset is developed using Empirical Quantile Mapping (EQM) for the historic (1951-2014) and projected (2015-2100) climate for the four scenarios (SSP126, SSP245, SSP370, SSP585) using output from 13 General Circulation Models (GCMs) from Coupled Model Intercomparison Project-6 (CMIP6). The bias-corrected dataset was evaluated against the observations for both mean and extremes of precipitation, maximum and minimum temperatures. Bias corrected projections from 13 CMIP6-GCMs project a warmer (3-5°C) and wetter (13-30%) climate in South Asia in the 21st century. The bias-corrected projections from CMIP6-GCMs can be used for climate change impact assessment in South Asia and hydrologic impact assessment in the sub-continental river basins.

Qualitative and Quantitative Analysis of Patients' Perceptions of the Patient Portal Experience with OpenNotes.

BACKGROUND: Access to medical encounter notes (OpenNotes) is believed to empower patients and improve the quality and safety of care. The impact of such access is not well understood beyond select health care systems and notes from primary care providers. OBJECTIVES: This article analyzes patients' perceptions about the patient portal experience with access to primary care and specialist's notes and evaluates free-text comments as an improvement opportunity. MATERIALS AND METHODS: Patients at an academic health care system who accessed the patient portal from February 2016 to May 2016 were provided a link to complete a 15-item online survey. Those who had viewed at least one note were asked about patient characteristics, frequency of note access, note usefulness, note understanding, and if any action was taken after accessing the note. Free-text comments were associated with nine questions which were analyzed using qualitative methods. RESULTS: A total of 23% (1,487/6,439) of patients who viewed the survey in the portal, participated. Seventy-six percent (1,126/1,487) knew that the notes were available on the portal, and of those, 957 had viewed at least one note to continue the survey. Ninety percent of those were older than 30 years of age, and 90% had some college education. The majority (83%) thought OpenNotes helped them take better care of themselves, without increasing worry (94%) or contacting the physician after reading the note (91%). The qualitative analysis of free-text responses demonstrated multiple positive and negative themes, and they were analyzed for potential improvement opportunities. CONCLUSION: Our survey confirms that patients who choose to access their primary care and specialists' online medical records perceive benefits of OpenNotes. Additionally, the qualitative analysis of comments revealed positive benefits and several potential patient portal improvement opportunities which could inform implementation of OpenNotes at other health systems.

Automating Vancomycin Monitoring to Improve Patient Safety.

INTRODUCTION: Intravenous vancomycin is a frequently used antibiotic and a common cause of medication-related harm because of its narrow therapeutic range. Improving monitoring of drug levels with automation in the electronic health record (EHR) may decrease this harm. METHODS: After examining the existing state of vancomycin ordering, administration, and monitoring, an automated process was created in the EHR that, on initiation of a new vancomycin order, automatically ordered a vancomycin trough level 30 minutes before the fourth dose. In addition, a nursing alert was integrated into the bar coding medication administration process that, if no trough level had been drawn by the time of the administration of the fourth dose, prompted the nurse to draw a trough level. Data from a three-month, post-implementation period was compared to data from a preceding three-month period. RESULTS: The frequency of trough levels drawn between the third and fourth dose increased from 58.6% to 75.8% (p < 0.01). However, the percentage of trough levels drawn within one hour of the fourth dose remained unchanged, possibly because nursing staff waited for the result of the level prior to administering the next dose of vancomycin. A minority of patients in both groups had trough levels that were in range (difference between groups, p = 0.46). CONCLUSION: Automation of vancomycin monitoring was associated with improvement in the frequency of monitoring and only delayed medication dosing by six minutes. Because vancomycin is high risk, this type of process should be broadly implemented, and outcomes should be assessed to identify unexpected outcomes and necessary further refinements.