Niina Ning Zhang576 (12b), de introduces the complement Mali qushi ‘Mary died’ to the noun xiaoxi ‘news’, and similarly in (17c), de introduces the internal argument dui jushi ‘to situation’ to the noun guanxin ‘concern’. (17) a. Mali guanxin jushi. Mali concern situation ‘Mali concerns the situation.’ b. Mali de guanxi Mali DE concern ‘Mali’s concern’ c. dui jushi de guanxin to situation DE concern ‘the concern about the situation’ The syntactic contrasts between modifiers and arguments have been attested in many aspects (Lebeaux 1988, 1991, Chomsky 1993, 2004, Rizzi 2004, among many others) (e.g. the reconstruction effects in binding; the argument-modifier contrasts have brought people to explore the syntactic operation “Late Merge”, in addition to Merge and Remerge). Since de may introduce an argument to a noun, its functions are more than that of a modification marker. General properties of de include the following. First, it occurs between two phrasal elements (Fan 1958, Huang 1989, Tang 1990:420, among others). This property reminds us of the so-called EPP or Edge feature (e.g. Chomsky 1995, 2008). The feature is defined as the obligatory availability of two phrases for certain functional heads, e.g. INFL and wh-question Q in English. The property itself indicates that de is a functional element. Second, the whole de-complex satisfies the c-selection of any element that selects a nominal, although the two phrases linked by de may not be nominal in other contexts. The word guanxin ‘concern’ is a verb in (17a), but when it follows de, as in (17b) and (17c), the whole complex is a nominal. In (12b), Mali qushi ‘Mary died’, which precedes de, is a clause, but the whole complex is again a nominal. De is obligatory in nominalization constructions. In (17a), for instance, there is no de in the clause. In (18), however, the bracketed constituent following the causer marker ba is a nominalized complex, and de must occur between the constituents of the complex. Thus de seems to be responsible for the nominal category of the whole complex. cita bibliográfica Muestra de cita Autor año De and the Functional Expansion of Classifiers 579 References Aboh, Enoch, Leston Buell, and Lisa L.-S. Cheng. 2011. Deriving the word order difference in the nominal domain: Gungbe vs. Mandarin. Paper presented at the Workshop on Analyticity, July 20, 2011. Hong Kong: University of Hong Kong. Adger, David, and Gillian Ramchand. 2005. Merge and move: wh-dependencies revisited. Linguistic Inquiry 36.2:161-193. Alexiadou, Artemis. 2001. Adjective syntax and noun raising: word order asymmetries in the DP as the result of adjective distribution. Studia Linguistica 55.3:217-248. Androutsopoulou, Antonia. 1994. The distribution of the definite determiner and the syntax of Greek DPs. Chicago Linguistic Society (CLS) 30:16-29. Chicago: Chicago Linguistic Society. Bhatt, Rajesh, and Shoichi Takahashi. 2011. Reduced and unreduced phrasal compara- tives. Natural Language and Linguistic Theory 29.3:581-620. Bisang, Walter. 1999. Classifiers in East and Southeast Asian languages: counting and beyond. Numeral Types and Changes Worldwide, ed. by Jadranka Gvozdanović, 113-185. Berlin & New York: Mouton de Gruyter. Bisang, Walter. 2011. Nominal and verbal classification─why the former is far more widespread than the latter. Paper presented at Association for Linguistic Typology 9 th Biennial Conference (ALT 9), July 21-24, 2011. Hong Kong: University of Hong Kong. Cheng, Lisa L.-S., and Rint Sybesma. 2005. A Chinese relative. Organizing Grammar: Linguistic Studies in Honor of Henk van Riemsdijk, ed. by Hans Broekhuis, Norbert Corver, Riny Huybregts, Ursula Kleinhenz & Jan Koster, 69-76. Berlin & New York: Mouton de Gruyter. Cheng, Lisa L.-S., and Rint Sybesma. 2009. De 的 as an underspecified classifier: first explorations. Yuyanxue Luncong [Essays on Linguistics] 39:123-156. Beijing: The Commercial Press. Chomsky, Noam. 1993. A minimalist program for linguistic theory. The View from Building 20: Essays in Linguistics in Honor of Sylvain Bromberger, ed. by Kenneth Hale & Samuel Jay Keyser, 1-52. Cambridge: MIT Press. Chomsky, Noam. 1995. The Minimalist Program. Cambridge: MIT Press. Chomsky, Noam. 2004. Beyond explanatory adequacy. Structures and Beyond: the Cartography of Syntactic Structures, Vol. 3, ed. by Adriana Belletti, 104-131. Oxford & New York: Oxford University Press. Chomsky, Noam. 2008. On phases. Foundational Issues in Linguistic Theory: Essays in Honor of Jean-Roger Vergnaud, ed. by Robert Freidin, Carlos Otero & Maria-Luisa Zubizarreta, 133-166. Cambridge: MIT Press. referencias bibliográficas 50 ANALYSE DE PATERNITÉ TEXTUELLE EN CONTEXTE JUDICIAIRE : UNE ASSISTANCE INFORMATISÉE POUR LE LINGUISTE Annie Houle Université Laval, Québec, Canada 1. Introduction Si, pour certains, le nom de Tim Evans évoque le personnage d’une ballade composée en 1953 par Ewan MacColl, pour d’autres, il rappelle plutôt un film de série noire des années 1970 intitulé 10, Rillington Place. Pour les Britanniques, ce nom revêt une importance majeure, puisqu’il symbolise l’abolition de la peine de mort dans leur pays. Pour les linguistes, le cas de Timothy Evans, un homme qu’on nous dépeint comme un simple d’esprit ayant été accusé et exécuté à tort pour le meurtre de sa fille, est le tremplin d’une nouvelle application des sciences du langage, puisque c’est dans The Evans Statements publié en 1968 par Jan Svartvik qu’on trouvera la première occurrence de l’expression forensic linguistics. Bien entendu, le domaine de la justice a eu recours à la linguistique bien avant que Svartvik n’utilise cette expression et l’eau a coulé sous les ponts depuis 1966, année où Tim Evans a reçu la grâce posthume. L’intérêt pour le domaine grandissant, les différentes disciplines de la linguistique, des plus classiques aux plus novatrices, trouvent application en contexte judiciaire. L’informatique étant devenue un des principaux vecteurs de la communication et le clavier le meilleur allié pour conserver l’anonymat, nous sommes de plus en plus heurtés aux délits de langue informatisés. En tenant compte de ces éléments ainsi que des avancées du traitement automatique du langage (TAL) en linguistique de corpus, les études sur l’analyse de la paternité textuelle assistée par ordinateur semblent se propager de façon naturelle, tendance à laquelle nous ne nous sommes pas soustraits. 2. Linguistique appliquée au domaine de la justice Si nous savons que l’expression forensic linguistics est apparue dans la littérature en 1968, il est plus difficile de déterminer à quel moment ce domaine a vu le jour. Chez nos contemporains, l’analyse des lettres de rançon dans l’affaire du kidnapping du fils de Charles Lindbergh (FBI – Federal Bureau of Investigation, s.d.), dans les années 30, semble être un avènement en la matière, mais si la linguistique se veut une science jeune, le langage est néanmoins un phénomène omniprésent et il ne faut pas se surprendre de la précocité avec laquelle la justice a eu recours aux experts de la langue. En effet, il semble que les sciences du langage aient été mises au profit de la justice britannique dès 1728, dans l’affaire William Hales (McMenamin, 2002 : 87). La venue de travaux significatifs dans le domaine est malgré tout assez tardive. Bryant publie, en 1930, une analyse sur le rôle que jouent les articles, prépositions et conjonctions dans les décisions juridiques. Cet ouvrage est ensuite réédité dans les années 1960 (en 1962, plus précisément), décennie pendant laquelle Wetter (1960) et Svartvik (1968) livrent les résultats de leurs analyses relatives, d’une part, au style des décisions juridiques en cour d’appel et, d’autre part, à la dualité des registres dans les témoignages et déclarations. Trente ans plus tard, des auteurs tels McMenamin (2002) et Olsson (2004) font mention de ces linguistes ayant contribué au développement de la linguistique appliquée au domaine de la justice et de leurs travaux qui, aujourd’hui encore, demeurent des incontournables. Depuis la publication de l’analyse pragmatique des litiges orientés sur les faits de Danet (1980), les travaux alliant linguistique et justice ne cessent de se multiplier et toute discipline de la linguistique semble y trouver son compte. L’étude systématique de la langue de la cour faite par O’Barr (1982), l’analyse discursive de Shuy (1993), ainsi que l’analyse linguistique multiple de Coulthard (1992, 2007) dans l’affaire Bentley, en sont autant d’exemples. Les recherches dans le domaine ont ensuite connu un essor considérable : des guides bibliographiques ont été publiés, des conférences ont été organisées, des cours ont été développés et présentés dans différentes universités, des périodiques ont vu le jour – notamment The International Journal of Speech, Language and the Law (IJSLL) – et des associations comme l’International Association of Forensic Linguistics (IAFL) ou l’International Language and Law Association (ILLA) ont été créées. Tous ces développements ont permis de définir un cadre propre aux études faites en linguistique appliquée au Muestra de cita Autor año A. Houle (2011) 60 nombre de phrases dans tous nos échantillons. Si tel est le cas, nous devrons nous interroger quant à la façon de sélectionner les séquences à étudier. Puisque le texte est un objet structuré (introduction, corps, conclusion), nous devrons déterminer si les mots ou les phrases à analyser seront pris en début ou tout au long du texte, afin de conserver certaines de ses caractéristiques structurales. De la même façon, d’autres marqueurs devront être pris en considération, par exemple, la présence de régionalismes ou de néologismes chez les différents auteurs. La répétition de fautes d’orthographe ou de frappe pourra également être des facteurs discriminants entre les auteurs. Il est certain que la petite taille des échantillons demeure la plus grande difficulté dans ce type d’étude, puisque baser des statistiques sur si peu de données peut parfois mener à des conclusions discutables. Il reste beaucoup à faire dans le domaine de l’analyse de paternité textuelle et encore davantage dans l’analyse des corpus en français, mais l’informatique demeure un allié des plus rapide et impartial pour le linguiste à l’affût des nouvelles technologies. L’analyse de la paternité textuelle a pour objectif ultime d’identifier l’auteur d’un texte, mais si cet objectif peut rarement être atteint avec une marge d’erreur raisonnable, il faut savoir que l’association ou la dissociation d’un texte à un auteur ou à un groupe peut être un résultat plus que satisfaisant pour qui s’y intéresse. Lorsqu’on parle de l’analyse de la paternité textuelle en contexte judiciaire, il faut être d’autant plus prudent, puisque la liberté d’un innocent pourrait être brimée. 12. Références BAKER, John Charles (1988) Pace: A Test of Authorship Based on the Rate at Which New Words Enter an Author's Text. Literary and Linguistic Computing Vol. 8, n o 1, p. 36-39. BRAINERD, Barron (1974) Weighing Evidence in Laguage and Literature: A Satistical Approach. Toronto, University of Toronto Press. BRYANT, Margaret M. (1962) English in the Law Courts: the Parts that Articles, Prepositions and Conjunctions Play in Legal Decisions. New York, Frederic Ungar. CHASKI, Carole E. (1997) Who Wrote It? Steps Toward a Science of Authorship. National Institute of Justice Journal. Vol. Septembre, p. 15-22. CHASKI, Carole E. (2001) Empirical Evaluation of Language-Based Author Identification Techniques. The International Journal of Speech, Language and the Law. Vol. 8, n o 1, p. 1-65. COULTHARD, Malcolm et Alison Johnson. (2007) Introducing Forensic Linguistics: Language in Evidence. London, Routledge. COULTHARD, Malcolm (1992) Forensic Discourse Analysis. Dans Advances in Spoken Discourse Analysis. London, Routledge, p. 242-258. DANET, Brenda (1980) Language in the Legal Process. Law Society Review. Vol. 3, p. 445-564. DE VEL, Olivier, Alison ANDERSON, Malcolm Walter CORNEY et George MOHAY (2001) Multi-Topic E- mail Authorship Attribution Forensics. Proceedings of ACM Conference on Computer Security Workshop on Data Mining for Security Applications. [En ligne] [http://citeseerx.ist.psu.edu/viewdoc/download?doi= 10.1.1.19.9951&rep=rep1&type=pdf] (Consulté le 21 octobre 2011) DIEDERICH, Joachim, Jörg KINDERMANN, Edda LEOPOLD et Gerhard PAASS (2003) Authorship Attribution with Support Vector Machines. Applied Intelligence. Vol. 1, n o 19, p. 109-123. ELLEGARD, Alvar (1962) A Statistical Method for Determining Authorship: The Junius Letters, 1769- 1772. Gothenburg, University of Gothenburg. ELLIS, Barbara G., et Steven J. DICK. (1996) Who Was “Shadow”? The Computer Knows: Applying Grammar-program Statistics in Content Analyses to Solve Mysteries about Authorship. Journalism & Mass Communication Quarterly. Vol. 73, n o 4, p. 947-962. FBI - FEDERAL BUREAU OF INVESTIGATION. The Lindbergh Kidnapping (s.d.) [en ligne], [http://www.fbi.gov/about-us/history/famous- cases/the-lindbergh-kidnapping] (Consulté le 30 avril 2011). FUCKS, Wilhelm (1952) On Mathematical Analysis of Style. Biometrika. Vol. 39, n o 1, p. 122-129. GRANT, Tim (2007) Quantifying Evidence in Forensic Authorship Analysis. International Journal of Speech Language and the Law, Vol. 14, n o 1, p. 1-25. And they that have done good things, shall come forth unto the resurrection of life; but they that have done evil, unto the resurrection of judgment and John 11: 21–27, which uses the Raising of Lazarus as a prototype for the resurrection of the dead: Martha therefore said to Jesus: Lord, if thou hadst been here, my brother had not died. But now also I know that whatsoever thou wilt ask of God, God will give it thee. Jesus saith to her: Thy brother shall rise again. Martha saith to him: I know that he shall rise again, in the resurrection at the last day. Jesus said to her: I am the resurrection and the life: he that believeth in me, although he be dead, shall live: And every one that liveth, and believeth in me, shall not die for ever. Believest thou this? She saith to him: Yea, Lord, I have believed that thou art Christ the Son of the living God, who art come into this world. The biblical account of the Raising of Lazarus then supplies a scriptural fons et origo for theological concatenations of general and particular judgment, heaven and earth, history and eternity. Remaining in Burgundy, we also observe how, also in the territories of the Dukes under their English dowager Duchess, Margaret of York, at the very end of the 15th century, the Visio Lazari was in vogue in a world of visual images and texts where manuscripts and printed books cross-fertilised one another. This was the same Burgundian court that produced Walter Marmion’s Vision of Tondall, and one of the most celebrated illuminated Apocalypses. At the centre of Van der Weyden’s altarpiece is the figure of St Michael weighing souls at Doomsday. St Michael offers a further link between Doomsday and Apocalypse narratives, for he is the angel who finally exposes Antichrist for what he is and resurrects Enoch and Elijah, and thus becomes the hero of the Chester Play of The Coming of Antichrist, and it is St Michael then who sounds the last trump for the souls to rise and be weighed on Doomsday. 48 Lazarus accreted through this mixed tradition of Burgundian popular hagi- ography and the vogue for visionary literature a peculiar status beyond his position in the chronological gospel account. Yet he remains an admonitory figure who offered material substantiation of the metaphysical realities of Doomsday, reducing the focus on the fate of the individual sinner from the graphic but still near-unimaginable horrors of being boiled in pitch, broken on wheels, force fed frogs, or slowly disemboweled, to a reminder of the lonely and claustrophobic fate of every corpse as witnessed at each and every funeral. In this context, Christ is no gentle Jesus, but the austere condemner of those who failed to heed earlier warnings about the fate of the habitual sinner’s soul. His approval was what stood between the individual sinner and the demons and devils, the destroyers and deceivers, and, at their centre, the terrifying 13 MEDIEVAL ENGLISH DRAMA a t U n i v e r s i d a d d e V a l e n c i a o n N o v e m b e r 2 1 , 2 0 1 2 h t t p : / / l i t t h e . o x f o r d j o u r n a l s . o r g / D o w n l o a d e d f r o m Muestra de cita en nota figure of the Antichrist. But balanced against the grim promise of the Visio Lazari, is Van der Weyden’s central luminous, white-clad archangel who presents the viewer with reassurance, and the cautiously optimistic encouragement with which medieval Roman Catholics faced the prospect of the last days. Though their approaches differ, all the dramatists variously contextualised here, following the pressure for renewal of the lay devotional agenda between the mid-15th-century and the Reformation, clearly had a number of rhet- orical, theological, and imaginative tools in their kit to provoke their audi- ences into a state of personal reflection in which the apocalyptic vision is morally inflected, personal, participatory, and probably imminent. REFERENCES 1 The ambitious Records of Early English Drama project, working since 1978, has, in the production of its county volumes and latterly on the Patrons and Performance web site, been instrumental in changing perceptions about the amount and nature of English drama before the commercial playhouse. See http://www.reed.utor onto.ca/. Accessed 26 May 2012. 2 The authoritative edition of the York Play is R. Beadle (ed.), The York Plays: A Critical Edition of the York Corpus Christi Play as recorded in British Library Additional MS 35290. Early English Text Society, supplementary series 23 (Oxford: OUP, 2009). The facsimile of the manuscript on which it is based is published as The York Play: A Facsimile of British Library MS Additional 35290, introduced by R. Beadle and P. Meredith (Leeds: University of Leeds School of English, 1983). 3 See T. French, The Great East Window (London: British Library, 2003). 4 New Advent: The Church Fathers, Augustine of Hippo, The City of God, book 11, available at http://www.new advent.org/fathers/120111.htm. Accessed 26 May 2012. 5 See A. Scafi, ‘Mapping the End: the Apocalypse in Medieval Cartography’ doi: 10.1093/litthe/frs049. 6 Scafi, ‘Mapping the End’. 7 Douay-Reims translation of the medieval Vulgate. 8 York, York Minster Library, MS. Add. 2. A fuller description of this manuscript and its relationship with the York Play can be found in P.M. King, ‘Corpus Christi Plays and the ‘‘Bolton Hours’’ 1: Tastes in Lay Piety and Patronage in Fifteenth- Century York’, Medieval English Theatre 18 (1998 for 1996), 46–62. 9 A.F. Johnston and M. Rogerson (eds) The Records of Early English Drama: York, 2 Vols, I (Toronto: University of Toronto Press, 1978), p. 17. See also P.M. King, ‘York Plays, Urban Piety, and the Case of Nicholas Blackburn, Mercer’, Archiv fur das Studium der neueren Sprachen und Literaturen, 232 (1995), 37–50. 10 P.J. Shaw, An Old York Church, All Hallows in North Street (York: All Saints’ North Street Shop, 1908). 11 M. Guest, ‘Keeping the End in Mind: Left Behind, the Apocalypse and the Evangelical Imagination’, doi: 10.1093/ litthe/frs053, quoting Gribben, Rapture Fiction, p. 56. 12 York, Borthwick Institute of Historical Research, Prob. 2, ff 605r–606r, trans- lated in Shaw, All Hallows, pp. 90–92. 13 REED: York, I, 55. 14 PAMELA KING a t U n i v e r s i d a d d e V a l e n c i a o n N o v e m b e r 2 1 , 2 0 1 2 h t t p : / / l i t t h e . o x f o r d j o u r n a l s . o r g / D o w n l o a d e d f r o m 34 Walker (ed.) Anthology, pp. 201–5. 35 The Macro Plays: The Castle of Perseverance, Wisdom, Mankind, M. Eccles (ed.) Early English Text Society, original series 262 (Oxford: OUP, 1969). 36 See Records of Early English Drama: Diocese of Canterbury, Kent, 3 Vols, J.M. Gibson (ed.) (Toronto: Toronto University Press, 2002) Vol. 1, pp. lix–lxiii; Vol. 2, pp. 738, 745–50, 779–94. 37 See The Coventry Corpus Christi Plays, P.M. King and C. Davidson (eds) (Kalamazoo: Medieval Institute Publications, Western Michigan University, 2000). 38 St Gregory the Great, Moralia in Job, 31, 45, Patrologia Latina 76, col. 621A. 39 The authoritative edition of the Towneley Plays is The Towneley Plays, M. Stevens and A.C. Cawley (eds) Early English Text Society, supplementary series 13 and 14 (Oxford: OUP, 1994). The facsimile of the manuscript is published as The Towneley Cycle: A Facsimile of Huntington MS HM 1, with an introduction by A.C. Cawley and M. Stevens (University of Leeds: School of English, 1976). 40 M. Jennings, ‘The Literary Career of the Recording Demon’, Studies in Philology: Texts and Studies, 74.5 (1977). 41 Eccles (ed.) Macro Plays. 42 See for example, P. Neuss, ‘Active and Idle Language in Mankind’, in P. Neuss (ed.) Aspects of Early English Drama (Cam- bridge: D.S. Brewer, 1983), pp. 112–28; J. Dillon, Language and Stage in Medieval and Renaissance England (Cambridge: Cambridge University Press, 1998), pp. 54–69. 43 The following account of the Towneley Raising of Lazarus summarises elements of my longer essay, ‘Finis huius: the Final Pageants in the Towneley Plays’, forthcoming in a volume of essays on the Towneley Manuscript edited by M. Twycross. 44 The kalender of Shepherdes. The edition of Paris 1503 in photographic facsimile. A faith- ful reprint of R. Pynson’s edition of London 1506, edited, with critical introduction by H. Oskar Sommer (London, 1892), pp. 66–67. 45 T. Kren, ‘Some Illuminated Manuscripts of The Vision of Lazarus from the Time of Margaret of York’, in T. Kren (ed.) Margaret of York, Simon Marmion, and The Visions of Tondall (Malibu, California: J. Paul Getty Museum, 1992), pp. 141–70. 46 L. Seidel, Legends in Limestone: Lazarus, Gislebertus, and the Cathedral of Autun (Chicago and London: University of Chicago Press, 1999), especially pp. 33– 62. 47 B.G. Lane, ‘ ‘‘Requiem Aeternam dona es’’: the Beaune ‘‘Last Judgment’’ and the Mass of the Dead’, Simiolus: Netherlands Quarterly for the History of Art, 19 (1989), 166–80. 48 R.F. Johnson, Saint Michael the Archangel in Medieval English Legend (Woodbridge: Boydell Press, 2005), p. 104. 16 PAMELA KING a t U n i v e r s i d a d d e V a l e n c i a o n N o v e m b e r 2 1 , 2 0 1 2 h t t p : / / l i t t h e . o x f o r d j o u r n a l s . o r g / D o w n l o a d e d f r o m Electronic Health Record Use, Intensity of Hospital Care, and Patient Outcomes Saul Blecker, MD, MHS, a,b Keith Goldfeld, DrPH, a Naeun Park, MS, a Daniel Shine, MD, b Jonathan S. Austrian, MD, b R. Scott Braithwaite, MD, MSc, a,b Martha J. Radford, MD, b Marc N. Gourevitch, MD, MPH a a Department of Population Health, New York University School of Medicine, New York; b Department of Medicine, New York University Langone Medical Center, New York. ABSTRACT OBJECTIVE: Previous studies have suggested that weekend hospital care is inferior to weekday care and that this difference may be related to diminished care intensity. The purpose of this study was to determine whether a metric for measuring intensity of hospital care based on use of the electronic health record was associated with patient-level outcomes. METHODS: We performed a cohort study of hospitalizations at an academic medical center. Intensity of care was defined as the hourly number of provider accessions of the electronic health record, termed “electronic health record interactions.” Hospitalizations were categorized on the basis of the mean difference in electronic health record interactions between the first Friday and the first Saturday of hospitalization. We used regression models to determine the association of these categories with patient outcomes after adjusting for covariates. RESULTS: Electronic health record interactions decreased from Friday to Saturday in 77% of the 9051 hospitalizations included in the study. Compared with hospitalizations with no change in Friday to Saturday electronic health record interactions, the relative lengths of stay for hospitalizations with a small, moderate, and large decrease in electronic health record interactions were 1.05 (95% confidence interval [CI], 1.00- 1.10), 1.11 (95% CI, 1.05-1.17), and 1.25 (95% CI, 1.15-1.35), respectively. Although a large decrease in electronic health record interactions was associated with in-hospital mortality, these findings were not significant after risk adjustment (odds ratio 1.74, 95% CI, 0.93-3.25). CONCLUSIONS: Intensity of inpatient care, measured by electronic health record interactions, significantly diminished from Friday to Saturday, and this decrease was associated with length of stay. Hospitals should consider monitoring and correcting temporal fluctuations in care intensity. Ó 2014 Elsevier Inc. All rights reserved. The American Journal of Medicine (2014) 127, 216-221 KEYWORDS: Electronic health record; Hospital medicine Weekend care in hospitals has been associated with poor patient outcomes. 1-7 Such temporal variations may reflect differences in the overall intensity of care delivered to patients on weekends compared with weekdays. Prior stu- dies, using surveys and detailed chart reviews, also have demonstrated that care delays are more common on weekends. 8,9 To measure and track the global intensity of hospital care, we recently developed a metric based on use of the hospital electronic health record. 10 We considered each opening of a patient record to represent an instance of individual patient care. Counting these accessions of the medical record, which we termed “electronic health record interactions,” was found to be a sensitive measure of temporal variations in care. At the level of the hospital, we observed a reduction in care intensity by two thirds on weekends compared with week- days. 10 To our knowledge, electronic health record in- teractions represent the first measure of global intensity of care in the contemporary hospital. Funding: SB was supported in part by National Center for Advancing Translational Sciences Grant KL2TR000053. Conflict of Interest: None. Authorship: All authors had access to the data and played a role in writing this manuscript. Requests for reprints should be addressed to Saul Blecker, MD, MHS, New York University School of Medicine, 227 E. 30th St, 648, New York, NY 10016. E-mail address:
[email protected] 0002-9343/$ -see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjmed.2013.11.010 CLINICAL RESEARCH STUDY Muestra de cita numerada spends in the hospital. Nonetheless, electronic health record interactions were not associated with readmission or mor- tality in our sample, suggesting that high acuity patients may be receiving sufficient care to prevent adverse outcomes. Both increased and decreased intensity from Friday to Saturday were associated with increased length of stay. This finding of poor outcomes among patients with an increase in electronic health record interactions may reflect individuals who had a clinical deterioration on Saturday. Such patients typically are transferred to an intensive care setting, where intensity of care increases and the likelihood of increased length of stay and mortality increases. The apparently anomalous finding of increased length of stay and a trend toward increased mortality among patients with increased electronic health record interactions is therefore a validation of the sensitivity of our intensity measurement. To help promote adoption of electronic health records to improve patient care, Medicare and Medicaid have offered financial incentives to hospitals for deployment of electronic health records that satisfy requirements for “meaningful use.” 14 The requirements for meaningful use include process measures and reporting of clinical quality metrics, with the goal of improving patient-level outcomes. 14,15 Electronic health record interactions could be considered a potential metric of meaningful use, as a process measure that seems to be related to temporal variations in care. Furthermore, find- ings that electronic health record interactions were associated with length of stay and had a nonsignificant association with mortality suggest that tracking and reducing variations in this metric as part of quality improvement efforts may have a meaningful impact on patient care and outcomes. Study Limitations First, although we adjusted for many potential confounders in our analysis, residual confounding may account for some of the results in this observational study. For instance, a provider may have decided on Friday that weekend discharge was unlikely for a certain patient and, as a result, reduced activity related to that patient on Saturday. This patient would have a large difference in Friday to Saturday interactions and a low likelihood of weekend discharge; in this case the associated relationship between electronic health record interactions and weekend discharge would be related to unmeasured confounders. Second, our study took place at a single institution and findings may not be generalizable to other contexts. Third, electronic health re- cord interactions may not always reflect actual patient care or clinical documentation, although this measure has been shown to be well correlated with patient orders. 10 Fourth, variations in the amount of care associated with each accession of a patient’s electronic health record may limit the validity of electronic health record interactions as a perfect measure of care intensity. Finally, readmissions were measured only if they occurred at the same institution, which may have led to misclassification if patients were readmitted to other hospitals. CONCLUSIONS We found that a weekend decline in intensity of care, typical of many hospitals, is associated with hospital processes and patient outcomes. By using electronic health record in- teractions as a global measure of intensity, the length of stay was adversely associated with a decrease in care intensity from Friday to Saturday. Taken together with previous work, these results suggest that hospitals should consider measuring and mitigating temporal fluctuations in the in- tensity of their services with a view to improve efficiency and, most likely, patient outcomes. References 1. Aujesky D, Jimenez D, Mor MK, Geng M, Fine MJ, Ibrahim SA. Weekend versus weekday admission and mortality after acute pulmo- nary embolism. Circulation. 2009;119:962-968. 2. Bell CM, Redelmeier DA. Mortality among patients admitted to hos- pitals on weekends as compared with weekdays. N Engl J Med. 2001;345:663-668. 3. Crowley RW, Yeoh HK, Stukenborg GJ, Medel R, Kassell NF, Dumont AS. Influence of weekend hospital admission on short-term mortality after intracerebral hemorrhage. Stroke. 2009;40:2387-2392. 4. Horwich TB, Hernandez AF, Liang L, et al. 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