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Many academic medical centers (AMCs) rely on systems like the Vizient Quality and Accountability Scorecard to track quality metrics such as the observed-to-expected (O/E) mortality ratio. The O/E mortality ratio calculation relies on clinical documentation. Missed documentation of diagnoses and risk factors for mortality leads to an underestimated expected mortality, which negatively affects the O/E metric.We aimed to reduce our O/E mortality ratio from a median of 1.08 (± 0.10) to [...]

The German Federal Ministry of Health introduced the Pflegepersonalregelung 2.0 (PPR 2.0) to address the nursing staffing crisis. It establishes a framework to determine personnel requirements, ensuring adequate staffing. However, the required daily classification of patient care levels imposes a significant administrative burden on nursing staff. Digitizing this process may reduce documentation time and enhance efficiency, but effectiveness depends on usability and acceptance.This study evaluates the acceptance and usability of [...]

Claude Opus 4 is a large language model (LLM) that features improved reasoning capabilities and broader contextual understanding compared to earlier versions. Despite the growing use of LLM systems for seeking medical information, structured and simulation-based evaluations of Claude Opus 4's capabilities in diabetes management remain limited, particularly across domains such as patient education, clinical reasoning, and emotional support.This study aimed to conduct a baseline evaluation of Claude Opus 4's [...]

Nurses are the largest group of electronic health record (EHR) users in Canada, yet their experiences with documentation burden remain underexplored. While EHR-generated usage data, such as audit logs and time-motion metrics, have been used to quantify documentation time, they are rarely used to better understand EHR inefficiencies and identify potential changes for nursing documentation and workflows. This approach may help address instances of documentation demands detracting from direct patient [...]

Achieving digital health equity and proper use of identity credentials is crucial as reliance on electronic modalities increases. Proxy access-now increasingly referred to as shared access-is a widely available functionality that offers identity credentials to care partners who assist loved ones in navigating the electronic care delivery demands of patients with complex care needs. However, adoption of these tools has been hindered by complicated user interfaces and low awareness.Drawing on [...]

This study aimed to evaluate the effect of optimizing the ambulatory medication preference list on provider efficiency in medication ordering.Using electronic health record (EHR) vendor data, a multidisciplinary informatics team optimized the general ambulatory medication preference list to better align with providers' ordering patterns. We conducted a pre-postintervention analysis assessing time-in-orders per encounter and number of manual changes per order.Postintervention, average manual changes per order decreased from 4.12 to 3.00 [...]

For every 30 minutes a provider spends seeing a patient, they spend 36 minutes charting in the electronic health record (EHR). Clinical documentation burden in U.S. health care is driven by increasing administrative tasks associated with EHRs, regulatory demands, and workflow inefficiencies. This burden contributes to increased cognitive load, fragmented care, and staff burnout. No comprehensive conceptual framework guides researchers addressing these challenges.This study aimed to develop a conceptual framework clarifying the [...]

Completion of Family and Medical Leave Act (FMLA) paperwork is a necessary but time-intensive task that contributes to clinician administrative burden.This study aimed to implement and evaluate an electronic health record (EHR)-integrated FMLA tool designed to reduce documentation time and improve workflow efficiency.An EHR-embedded FMLA form was deployed at a large academic medical center, piloted in July 2024 in primary care, and expanded to all ambulatory practices in September 2024 [...]

Problem lists are intended to support high-quality care, but are often long and outdated. Despite policy efforts to encourage their upkeep-such as the "Problem List Reviewed" attestation checkbox in electronic health records (EHRs)-many diagnoses remain on lists far longer than clinically appropriate. Clinicians often check the attestation box that problem lists have been reviewed to comply with performance measures without reviewing and modifying the list.This study aimed to assess whether [...]

Malnutrition remains a critical global health challenge among hospitalized patients, necessitating effective nutrition support systems.This study aims to construct and evaluate a cross-professional, cross-sectoral nutrition health care information system (CPCS-NHIS) to optimize clinical nutrition management.The system integrates modified medical systems to unify information flows, knowledge, and clinical roles. In addition, a 20-item across six dimensions electronic questionnaire based on the revised DeLone and McLean IS Success model was developed to [...]