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(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 thenoun guanxin ‘concern’.

(17) a. Mali guanxin jushi.Mali concern situation‘Mali concerns the situation.’

b. Mali de guanxiMali DE concern‘Mali’s concern’

c. dui jushi de guanxinto situation DE concern‘the concern about the situation’

The syntactic contrasts between modi ers and arguments have been attested inmany aspects (Lebeaux 1988, 1991, Chomsky 1993, 2004, Rizzi 2004, among manyothers) (e.g. the reconstruction effects in binding; the argument-modi er contrasts have

brought people to explore the syntactic operation “Late Merge”, in addition to Mergeand Remerge). Since de may introduce an argument to a noun, its functions are morethan that of a modi cation marker.

General properties of de include the following. First, it occurs between two phrasalelements (Fan 1958, Huang 1989, Tang 1990:420, among others). This property remindsus of the so-called EPP or Edge feature (e.g. Chomsky 1995, 2008). The feature is de nedas the obligatory availability of two phrases for certain functional heads, e.g. INFL andwh-question Q in English. The property itself indicates that de is a functional element.

Second, the whole de-complex satis es the c-selection of any element that selects anominal, 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 nominalizedcomplex, and de must occur between the constituents of the complex. Thus de seems to

be responsible for the nominal category of the whole complex.

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De and the Functional Expansion of Classifiers

579

References

Aboh, Enoch, Leston Buell, and Lisa L.-S. Cheng. 2011. Deriving the word orderdifference in the nominal domain: Gungbe vs. Mandarin. Paper presented at theWorkshop 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 asymmetriesin the DP as the result of adjective distribution. Studia Linguistica 55.3:217-248.

Androutsopoulou, Antonia. 1994. The distribution of the de nite determiner and thesyntax 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. Classi ers in East and Southeast Asian languages: counting and

beyond. Numeral Types and Changes Worldwide , ed. by Jadranka Gvozdanovi ć ,113-185. Berlin & New York: Mouton de Gruyter.

Bisang, Walter. 2011. Nominal and verbal classi cation ─ why the former is far morewidespread than the latter. Paper presented at Association for Linguistic Typology9th Biennial Conference (ALT 9), July 21-24, 2011. Hong Kong: University ofHong 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 as an underspeci ed classi er: rstexplorations. Yuyanxue Luncong [ Essays on Linguistics ] 39:123-156. Beijing: TheCommercial 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 KennethHale & 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-LuisaZubizarreta, 133-166. Cambridge: MIT Press.

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50

ANALYSE DE PATERNITÉ TEXTUELLE EN CONTEXTE JUDICIAIRE :UNE ASSISTANCE INFORMATISÉE POUR LE LINGUISTE

Annie HouleUniversité Laval, Québec, Canada

1. IntroductionSi, pour certains, le nom de Tim Evans évoque le

personnage d’une ballade composée en 1953 parEwan MacColl, pour d’autres, il rappelle plutôt unfilm de série noire des années 1970 intitulé 10,

Rillington Place . Pour les Britanniques, ce nom revêtune importance majeure, puisqu’il symbolisel’abolition de la peine de mort dans leur pays. Pourles linguistes, le cas de Timothy Evans, un hommequ’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 dessciences du langage, puisque c’est dans The EvansStatements publié en 1968 par Jan Svartvik qu’ontrouvera la première occurrence de l’expression

forensic linguistics . Bien entendu, le domaine de la justice a eu recours à la linguistique bien avant queSvartvik n’utilise cette expression et l’eau a coulésous les ponts depuis 1966, année où Tim Evans areçu la grâce posthume.

L’intérêt pour le domaine grandissant, lesdifférentes disciplines de la linguistique, des plusclassiques aux plus novatrices, trouvent applicationen contexte judiciaire. L’informatique étant devenueun des principaux vecteurs de la communication et leclavier le meilleur allié pour conserver l’anonymat,nous sommes de plus en plus heurtés aux délits delangue informatisés. En tenant compte de ceséléments ainsi que des avancées du traitementautomatique du langage (TAL) en linguistique decorpus, les études sur l’analyse de la paternitétextuelle assistée par ordinateur semblent se propagerde façon naturelle, tendance à laquelle nous ne noussommes pas soustraits.

2. Linguistique appliquée au domaine de la justiceSi nous savons que l’expression forensic

linguistics est apparue dans la littérature en 1968, ilest plus difficile de déterminer à quel moment cedomaine a vu le jour. Chez nos contemporains,l’analyse des lettres de rançon dans l’affaire dukidnapping du fils de Charles Lindbergh (FBI –Federal Bureau of Investigation, s.d.), dans les années30, semble être un avènement en la matière, mais si la

linguistique se veut une science jeune, le langage estnéanmoins 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 misesau profit de la justice britannique dès 1728, dansl’affaire William Hales (McMenamin, 2002 : 87).

La venue de travaux significatifs dans le domaineest 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 lesannées 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’appelet, d’autre part, à la dualité des registres dans lestémoignages et déclarations. Trente ans plus tard, desauteurs tels McMenamin (2002) et Olsson (2004) fontmention de ces linguistes ayant contribué audéveloppement de la linguistique appliquée audomaine de la justice et de leurs travaux qui,

aujourd’hui encore, demeurent des incontournables.Depuis la publication de l’analyse pragmatique deslitiges orientés sur les faits de Danet (1980), lestravaux alliant linguistique et justice ne cessent de semultiplier et toute discipline de la linguistique sembley trouver son compte. L’étude systématique de lalangue de la cour faite par O’Barr (1982), l’analysediscursive de Shuy (1993), ainsi que l’analyselinguistique multiple de Coulthard (1992, 2007) dansl’affaire Bentley, en sont autant d’exemples.

Les recherches dans le domaine ont ensuite connuun essor considérable : des guides bibliographiques

ont été publiés, des conférences ont été organisées,des cours ont été développés et présentés dansdifférentes universités, des périodiques ont vu le jour

– notamment The International Journal of Speech, Language and the Law (IJSLL) – et des associationscomme l’ International Association of Forensic

Linguistics (IAFL) ou l’ International Language and Law Association (ILLA) ont été créées. Tous cesdéveloppements ont permis de définir un cadre propreaux études faites en linguistique appliquée au

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A. Houle (2011) 60

nombre de phrases dans tous nos échantillons. Si telest le cas, nous devrons nous interroger quant à lafaçon de sélectionner les séquences à étudier. Puisquele texte est un objet structuré (introduction, corps,conclusion), nous devrons déterminer si les mots oules phrases à analyser seront pris en début ou tout au

long du texte, afin de conserver certaines de sescaractéristiques structurales. De la même façon,d’autres marqueurs devront être pris en considération,

par exemple, la présence de régionalismes ou denéologismes chez les différents auteurs. La répétitionde fautes d’orthographe ou de frappe pourraégalement être des facteurs discriminants entre lesauteurs. Il est certain que la petite taille deséchantillons demeure la plus grande difficulté dans cetype d’étude, puisque baser des statistiques sur si peude données peut parfois mener à des conclusionsdiscutables. Il reste beaucoup à faire dans le domaine

de l’analyse de paternité textuelle et encore davantagedans l’analyse des corpus en français, maisl’informatique demeure un allié des plus rapide etimpartial pour le linguiste à l’affût des nouvellestechnologies.

L’analyse de la paternité textuelle a pour objectifultime d’identifier l’auteur d’un texte, mais si cetobjectif peut rarement être atteint avec une marged’erreur raisonnable, il faut savoir que l’associationou la dissociation d’un texte à un auteur ou à ungroupe peut être un résultat plus que satisfaisant pourqui s’y intéresse. Lorsqu’on parle de l’analyse de la

paternité textuelle en contexte judiciaire, il faut êtred’autant plus prudent, puisque la liberté d’un innocent

pourrait être brimée.

12. Références

BAKER , John Charles (1988) Pace: A Test ofAuthorship Based on the Rate at Which New WordsEnter an Author's Text. Literary and LinguisticComputing 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 andConjunctions Play in Legal Decisions . New York,Frederic Ungar.

CHASKI , Carole E. (1997) Who Wrote It? StepsToward a Science of Authorship. National Instituteof Justice Journal. Vol. Septembre, p. 15-22.

CHASKI , Carole E. (2001) Empirical Evaluation ofLanguage-Based Author Identification Techniques.The International Journal of Speech, Language andthe 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 DiscourseAnalysis. Dans Advances in Spoken Discourse

Analysis . London, Routledge, p. 242-258.

DANET , Brenda (1980) Language in the LegalProcess. Law Society Review. Vol. 3, p. 445-564.

DE VEL , Olivier, Alison A NDERSON , Malcolm Walter CORNEY et George M OHAY (2001) Multi-Topic E-mail Authorship Attribution Forensics. Proceedingsof 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 le21 octobre 2011)

DIEDERICH , Joachim, Jörg K INDERMANN , EddaLEOPOLD et Gerhard P AASS (2003) AuthorshipAttribution 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. D ICK . (1996) WhoWas “Shadow”? The Computer Knows: ApplyingGrammar-program Statistics in Content Analyses toSolve Mysteries about Authorship. Journalism &

Mass Communication Quarterly. Vol. 73, n o 4, p.947-962.

FBI - FEDERAL BUREAU OF I NVESTIGATION . TheLindbergh Kidnapping (s.d.) [en ligne],[http://www.fbi.gov/about-us/history/famous-cases/the-lindbergh-kidnapping] (Consulté le30 avril 2011).

FUCKS , Wilhelm (1952) On Mathematical Analysisof Style. Biometrika. Vol. 39, n o 1, p. 122-129.

GRANT , Tim (2007) Quantifying Evidence inForensic Authorship Analysis. International

Journal of Speech Language and the Law , Vol. 14,no 1, p. 1-25.

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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 theresurrection of the dead:

Martha therefore said to Jesus: Lord, if thou hadst been here, my brother had notdied. But now also I know that whatsoever thou wilt ask of God, God will give itthee. Jesus saith to her: Thy brother shall rise again. Martha saith to him: I knowthat he shall rise again, in the resurrection at the last day. Jesus said to her: I am theresurrection 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. Believestthou 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, heavenand earth, history and eternity.

Remaining in Burgundy, we also observe how, also in the territories of theDukes under their English dowager Duchess, Margaret of York, at the veryend of the 15 th century, the Visio Lazari was in vogue in a world of visualimages and texts where manuscripts and printed books cross-fertilised oneanother. This was the same Burgundian court that produced Walter Marmion’s Vision of Tondall, and one of the most celebrated illuminatedApocalypses. At the centre of Van der Weyden’s altarpiece is the gure of St Michael weighing souls at Doomsday. St Michael offers a further linkbetween Doomsday and Apocalypse narratives, for he is the angel who nallyexposes Antichrist for what he is and resurrects Enoch and Elijah, and thusbecomes the hero of the Chester Play of The Coming of Antichrist, and it is StMichael 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 hisposition in the chronological gospel account. Yet he remains an admonitorygure who offered material substantiation of the metaphysical realities of Doomsday, reducing the focus on the fate of the individual sinner from thegraphic but still near-unimaginable horrors of being boiled in pitch, broken onwheels, force fed frogs, or slowly disemboweled, to a reminder of the lonelyand 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 thosewho 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

13MEDIEVAL ENGLISH DRAMA

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gure of the Antichrist. But balanced against the grim promise of theVisio Lazari , is Van der Weyden’s central luminous, white-clad archangelwho presents the viewer with reassurance, and the cautiously optimisticencouragement with which medieval Roman Catholics faced the prospectof the last days.

Though their approaches differ, all the dramatists variously contextualisedhere, following the pressure for renewal of the lay devotional agenda betweenthe mid- 15 th-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 reection in which the apocalyptic vision ismorally inected, personal, participatory, and probably imminent.

REFERENCES

1The ambitious Records of Early EnglishDrama project, working since 1978 , has,in the production of its county volumesand latterly on the Patrons and Performance web site, been instrumental in changingperceptions about the amount and natureof English drama before the commercial

playhouse. See http://www.reed.utor onto.ca/ . Accessed 26 May 2012 .

2The authoritative edition of the YorkPlay 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 manuscripton 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 ).

3See T. French, The Great East Window (London: British Library, 2003 ).

4New Advent: The Church Fathers,Augustine of Hippo, The City of God ,book 11 , available at http://www.new

advent.org/fathers/ 120111 .htm . Accessed26 May 2012 .

5See A. Sca, ‘Mapping the End: theApocalypse in Medieval Cartography’d l h f

6Sca, ‘Mapping the End’.

7Douay-Reims translation of the medievalVulgate.

8 York, York Minster Library, MS. Add. 2.A fuller description of this manuscript andits relationship with the York Play can befound in P.M. King, ‘Corpus Christi

Plays and the ‘‘Bolton Hours’’ 1: Tastesin Lay Piety and Patronage in Fifteenth-Century York’, Medieval English Theatre 18 (1998 for 1996 ), 46 – 62 .

9A.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 alsoP.M. King, ‘York Plays, Urban Piety,and the Case of Nicholas Blackburn,

Mercer’, Archiv fur das Studium der neuerenSprachen und Literaturen, 232 (1995 ),37 – 50 .

10P.J. Shaw, An Old York Church, All Hallows in North Street (York: All Saints’North Street Shop, 1908 ).

11M. Guest, ‘Keeping the End in Mind:Left Behind , the Apocalypse and theEvangelical Imagination’, doi: 10 .1093 /litthe/frs 053 , quoting Gribben, Rapture

Fiction, p. 56 .12 York, Borthwick Institute of HistoricalResearch, Prob. 2, ff 605 r– 606 r, trans-lated in Shaw, All Hallows, pp. 90 – 92 .

13k

14 PAMELA KING

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34Walker (ed.) Anthology, pp. 201 – 5 .

35The Macro Plays: The Castle of Perseverance,Wisdom, Mankind, M. Eccles (ed.) EarlyEnglish Text Society, original series 262

(Oxford: OUP, 1969 ).36See 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 .

37See The Coventry Corpus Christi Plays,P.M. King and C. Davidson (eds)(Kalamazoo: Medieval InstitutePublications, Western Michigan

University, 2000 ).38St Gregory the Great, Moralia in Job, 31 ,45 , Patrologia Latina 76 , col. 621 A.

39The authoritative edition of the TowneleyPlays is The Towneley Plays, M. Stevens andA.C. Cawley (eds) Early English TextSociety, 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 ).

40M. Jennings, ‘The Literary Career of theRecording Demon’, Studies in Philology:Texts and Studies, 74 .5 (1977 ).

41Eccles (ed.) Macro Plays.

42See for example, P. Neuss, ‘Active andIdle 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 .

43The following account of the Towneley

Raising of Lazarus summarises elementsof my longer essay, ‘Finis huius: theFinal Pageants in the Towneley Plays’,forthcoming in a volume of essays onthe Towneley Manuscript edited by M.Twycross.

44The kalender of Shepherdes. The edition of Paris 1503 in photographic facsimile. A faith-

ful reprint of R. Pynson’s edition of London1506 , edited, with critical introduction by

H. Oskar Sommer (London, 1892 ), pp.66 – 67 .45

T. Kren, ‘Some Illuminated Manuscriptsof 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 .

46L. Seidel, Legends in Limestone: Lazarus,

Gislebertus, and the Cathedral of Autun(Chicago and London: University of Chicago Press, 1999 ), especially pp. 33 – 62 .

47B.G. Lane, ‘ ‘‘Requiem Aeternam donaes’’: the Beaune ‘‘Last Judgment’’ and theMass of the Dead’, Simiolus: NetherlandsQuarterly for the History of Art, 19 (1989 ),166 – 80 .

48R.F. Johnson, Saint Michael the Archangel

in Medieval English Legend (Woodbridge:Boydell Press, 2005 ), p. 104 .

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Electronic Health Record Use, Intensity of Hospital Care,and Patient OutcomesSaul 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, MPHa

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 wasassociated with patient-level outcomes.METHODS: We performed a cohort study of hospitalizations at an academic medical center. Intensity of carewas de ned as the hourly number of provider accessions of the electronic health record, termed “ electronichealth record interactions. ” Hospitalizations were categorized on the basis of the mean difference inelectronic health record interactions between the rst Friday and the rst Saturday of hospitalization. Weused 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 9051hospitalizations included in the study. Compared with hospitalizations with no change in Friday to Saturdayelectronic 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% con dence 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 inelectronic health record interactions was associated with in-hospital mortality, these ndings were not signi cant after risk adjustment (odds ratio 1.74, 95% CI, 0.93-3.25).CONCLUSIONS: Intensity of inpatient care, measured by electronic health record interactions, signi cantlydiminished from Friday to Saturday, and this decrease was associated with length of stay. Hospitals shouldconsider monitoring and correcting temporal uctuations in care intensity.

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 re ect 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

demonstra ted that care delays are more common onweekends. 8,9

To measure and track the global intensity of hospital care,

we recently developed a m etric based on use of the hospitalelectronic 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, whichwe termed “ electronic health record interactions, ” was foundto be a sensitive measure of temporal variations in care. At the level of the hospital, we observed a reduction in careintensit y by two thirds on weekends compared with week-days. 10 To our knowledge, electronic health record in-teractions represent the rst measure of global intensity of care in the contemporary hospital.

Funding: SB was supported in part by National Center for AdvancingTranslational Sciences Grant KL2TR000053.

Con ict 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: saul.blecker@nyumc.org

0002-9343/$ -see front matter 2014 Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.amjmed.2013.11.010

CLINICAL RESEARCH STUDY

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spends in the hospital. Nonetheless, electronic health recordinteractions were not associated with readmission or mor-tality in our sample, suggesting that high acuity patients maybe receiving suf cient care to prevent adverse outcomes.

Both increased and decreased intensity from Friday toSaturday were associated with increased length of stay.This nding of poor outcomes among patients with an

increase in electronic health record interactions may re ect individuals who had a clinical deterioration on Saturday.Such patients typically are transferred to an intensive caresetting, where intensity of care increases and the likelihoodof increased length of stay and mortality increases. Theapparently anomalous nding of increased length of stayand a trend toward increased mortality among patientswith increased electronic health record interactions istherefore a validation of the sensitivity of our intensitymeasurement.

To help promote adoption of electronic health records toimprove patient care, Medicare and Medicaid have offered

nancial incentives to hospitals for deployment of electronichealt h records that satisfy requirements for “ meaningfuluse. ” 14 The requirements for meaningful use include processmeasures and reporting of clinical quality m etrics, with thegoal of improving patient-level outcomes. 14,15 Electronichealth record interactions could be considered a potentialmetric of meaningful use, as a process measure that seems tobe related to temporal variations in care. Furthermore, nd-ings that electronic health record interactions were associatedwith length of stay and had a nonsigni cant associationwith mortality suggest that tracking and reducing variationsin this metric as part of quality improvement efforts may

have a meaningful impact on patient care and outcomes.

Study LimitationsFirst, although we adjusted for many potential confoundersin our analysis, residual confounding may account for someof the results in this observational study. For instance, a provider may have decided on Friday that weekenddischarge was unlikely for a certain patient and, as a result,reduced activity related to that patient on Saturday. Thispatient would have a large difference in Friday to Saturdayinteractions and a low likelihood of weekend discharge; in

this case the associated relationship between electronichealth record interactions and weekend discharge would berelated to unmeasured confounders. Second, our study took place at a single institution and ndings may not begeneralizable to other contexts. Third, electronic health re-cord interactions may not always re ect actual patient careor clinical documentation, although this measure has beenshown to be well correlated with patient orders. 10 Fourth,variations in the amount of care associated with eachaccession 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 misclassi cation if patients werereadmitted to other hospitals.

CONCLUSIONSWe found that a weekend decline in intensity of care, typicalof many hospitals, is associated with hospital processes andpatient outcomes. By using electronic health record in-teractions as a global measure of intensity, the length of staywas adversely associated with a decrease in care intensityfrom Friday to Saturday. Taken together with previouswork, these results suggest that hospitals should consider measuring and mitigating temporal uctuations in the in-tensity of their services with a view to improve ef ciencyand, most likely, patient outcomes.

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