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Clinical documentation improvement is critical for pediatric care, yet leveraging electronic health record (EHR) tools for this population is not well established. We aimed to adapt and implement a real-time, automated documentation assistance tool (AutoDx) to decrease clinical documentation integrity (CDI) coding queries and improve perceived ease of practice for pediatric inpatient providers.In this quality improvement study at an urban academic pediatric hospital, we adapted and implemented AutoDx for pediatric [...]

Pain medicine triage plays a crucial role in ensuring patients receive timely and appropriate care by scheduling them to the most suitable treatment path. However, the absence of standardized triage protocols in pain medicine often leads to inefficiencies, including delay of care and wastage of healthcare resources.This study aims to develop a rule-based automated referral triage system leveraging information from patients' medical notes for scheduling patients to specific procedures in [...]

Effective communication in the intensive care unit (ICU) is essential, particularly for patients with non-English language preference, yet timely access to professional interpreters remains limited. While artificial intelligence (AI)-based translation tools have been explored in outpatient and nonacute care settings, studies evaluating their use in acute care, environments such as the ICU remain limited. To address this gap, we developed AI-TransLATE (AI-enhanced Transition to Language-Agnostic Transcultural Engagement), a speech-based translation [...]

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 [...]