Advancing intelligent closed-loop quality control in nursing documentation: opportunities and next steps.
Author(s): Cheng, Weihao
DOI: 10.1093/jamia/ocag022
Author(s): Cheng, Weihao
DOI: 10.1093/jamia/ocag022
Our study aims to assess the time-cost burden reduction of transitioning from manual case reporting to electronic case reporting (eCR) for COVID-19 among healthcare organizations (HCOs) over a 1-year period.
Author(s): Rincón-Guevara, Oscar, Olorukooba, Abdulhakeem A, Eau, Grace, Ritchey, Matthew D, Conn, Laura A, Knicely, Kimberly
DOI: 10.1093/jamia/ocag011
Efficient exchange of health information requires consistent representation of clinical concepts across laboratories, hospitals, and public health systems. LOINC supports this interoperability by standardizing laboratory test codes, but mapping remains difficult when datasets are incomplete, inconsistently formatted, or structurally diverse. These challenges often create a mismatch between algorithmic performance in controlled settings and real-world deployment. This study aimed to develop a biomedical natural language processing (NLP) approach for mapping heterogeneous [...]
Author(s): Naliyatthaliyazchayil, Parvati, Sangam, Venkat Ramana, Amlung, Joseph, Kanter, Andrew S, Purkayastha, Saptarshi, Payne, Jonathan
DOI: 10.1093/jamia/ocag010
To comprehensively evaluate the validity of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes for both prevalent diagnoses and less common diseases, and to assess the performance of a large language model (LLM)-based system in validating these codes.
Author(s): Wang, Yichen, Song, Yilin, Siu, Rex, Nimma, Induja R, Yan, Yan, Savage, Thomas R, Wang, Yiming, Li, Zhichen, Ramai, Daryl, Wang, Jiale, Badurdeen, Dilhana, Tao, Cui, Kumbhari, Vivek, Huang, Yuting
DOI: 10.1093/jamia/ocag008
Health-related social needs (HRSN) significantly influence health outcomes, yet healthcare organizations face persistent challenges tracking referrals to community-based organizations and interpreting referral outcomes across fragmented clinical and social care systems. Prior studies report low referral fulfillment rates, but much of this evidence derives from single organizations, manual data collection, or incentivized documentation workflows, limiting insight into how information infrastructure shapes what is observable at scale.
Author(s): Sockolow, Paulina S, Algur, Yasemin, Vader, Daniel, Chou, Edgar Y
DOI: 10.1055/a-2917-6605
Patients living with dementia (PLWD) require attention to social determinants of health (SDoH), but social information is often unavailable or incomplete during care encounters, and clinicians report uncertainty about how to act on this information.
Author(s): Alfaqih, Miad Ahemd, Haessner, Philipp, LeLaurin, Jennifer H, Guo, Jingchuan, Hammer, Nicole C, Ike-Okpe, Onyekachi, Pappa, Michael J, He, Xing, Salloum, Ramzi G, Bian, Jiang, Gregory, Megan E
DOI: 10.1055/a-2917-6503
In our recent study we showed that GPT's ability to perform OPS-code extraction from operational reports was equivalent to coding neurosurgeons. In this study we aim to evaluate the effect of context enhancement on GPT-5's code extraction abilities.
Author(s): Lehmann, Sebastian, Wilhelmy, Florian, Schwaebe, Frederic V, von Dercks, Nikolaus, Güresir, Erdem, Wach, Johannes S
DOI: 10.1055/a-2913-8450
Hospital artificial intelligence (AI) is increasingly embedded in electronic health record workflows, cloud inference pipelines, imaging, medication review, triage, early warning, documentation, and operational management. This paper proposes a risk-tiered governance framework and implementation pathway for hospital AI applications that are integrated into clinical and operational workflows.
Author(s): Zhu, Mengying, Luo, Bingjie, Wu, Xiaodong, Zhao, Ying, Wang, Shoujing, Hu, Yang, Liu, Ran, Zhang, Congyin, Li, Ji, Wang, Hongpan, Wang, Dijia, Liu, Liwen, Li, Yuehua
DOI: 10.1055/a-2921-5990
This study evaluated the effect of a Spatial Awareness Integrated Electronic Health Record (SAI-EHR) prototype on efficiency, usability, and cognitive workload among intensive care nurses performing standardized documentation tasks, compared with a traditional linear flowsheet-style interface (LID-EHR).
Author(s): Taylor-Vaughan, Lee, Helena, Morrison W, Silva Torres, Graciela E, Shea, Kimberly D, Reed, Pamela G, Gephart, Sheila M
DOI: 10.1055/a-2903-5822
Clinical documentation consumes substantial clinician time, potentially detracting from patient care. Generative artificial intelligence (AI) may support drafting discharge summaries and patient referral documents, but feasibility in non-Western-language oncology settings using real-world electronic health record (EHR) data remains insufficiently evaluated. This study assessed feasibility in a Japanese cancer hospital using an enterprise AI system.
Author(s): Michihata, Nobuaki, Ishii, Hiroshi, Tsujimura, Hideki, Takano, Nobuya, Nomura, Takuji, Takeuchi, Yoshihisa, Kagawa, Shingo, Asai, Shunichi, Kita, Emiri, Komaru, Atsushi, Suito, Hiroshi, Koga, Kunishige, Miura, Yoshifumi, Washio, Aya, Hippo, Yoshitaka
DOI: 10.1055/a-2917-6695