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Clinical documentation is central to patient care. The success of electronic health record system adoption may depend on how well such systems support clinical documentation. A major goal of integrating clinical documentation into electronic heath record systems is to generate reusable data. As a result, there has been an emphasis on deploying computer-based documentation systems that prioritize direct structured documentation. Research has demonstrated that healthcare providers value different factors when [...]

Pharmacy clinical decision-support (CDS) software that contains drug-drug interaction (DDI) information may augment pharmacists' ability to detect clinically significant interactions. However, studies indicate these systems may miss some important interactions. The purpose of this study was to assess the performance of pharmacy CDS programs to detect clinically important DDIs.

'Semantic Interoperability' is a driving objective behind many of Health Level Seven's standards. The objective in this paper is to take a step back, and consider what semantic interoperability means, assess whether or not it has been achieved, and, if not, determine what concrete next steps can be taken to get closer. A framework for measuring semantic interoperability is proposed, using a technique called the 'Single Logical Information Model' framework [...]

A supervised machine learning approach to discover relations between medical problems, treatments, and tests mentioned in electronic medical records.

Expert authorities recommend clinical decision support systems to reduce prescribing error rates, yet large numbers of insignificant on-screen alerts presented in modal dialog boxes persistently interrupt clinicians, limiting the effectiveness of these systems. This study compared the impact of modal and non-modal electronic (e-) prescribing alerts on prescribing error rates, to help inform the design of clinical decision support systems.

Many Dutch hospitals have established internal systems for reporting incidents. However, such internal systems do not allow learning from incidents that occur in other hospitals. Therefore a multicenter, information technology (IT) supported reporting system named central medication incidents registration (CMR) was developed. This article describes the architecture, implementation and current status of the CMR in The Netherlands and compare it with similar systems in other countries.

To present a partnership-based and community-oriented approach designed to ease provider anxiety and facilitate the implementation of electronic health records (EHR) in resource-limited primary care settings.

To compare the use of structured reporting software and the standard electronic medical records (EMR) in the management of patients with bladder cancer. The use of a human factors laboratory to study management of disease using simulated clinical scenarios was also assessed.