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BACKGROUND: Standardization of sign-out, the transfer of patient information and responsibility between inpatient providers at shift change, is a Joint Commission National Patient Safety Goal intended to improve communication and reduce risk of error. Computerized systems with free text data entry and limited structure allow clinicians to generate sign-out notes in a variety of ways. OBJECTIVES: The literature lacks a systematic exploration of the range of content generated by users [...]

Clinical notes summarize interactions that occur between patients and healthcare providers. With adoption of electronic health record (EHR) and computer-based documentation (CBD) systems, there is a growing emphasis on structuring clinical notes to support reusing data for subsequent tasks. However, clinical documentation remains one of the most challenging areas for EHR system development and adoption. The current manuscript describes the Vanderbilt experience with implementing clinical documentation with an EHR system [...]

BACKGROUND: Implementation of Computerized Provider Order Entry (CPOE) can fail or meet high levels of user resistance for a variety of reasons, including lack of attention to users' needs and the significant workflow changes induced and required by CPOE. End-user satisfaction is a critical factor in IT implementation. OBJECTIVE: The goal of this study was to identify criteria to select a valid and reliable questionnaire to measure end-user satisfaction with [...]

The International Classification of Functioning, Disability and Health (ICF) is the World Health Organization's standard for describing health and health-related states. Examples of how the ICF has been used in Electronic Health Records (EHRs) have not been systematically summarized and described yet.

Big data or population-based information has the potential to reduce uncertainty in medicine by informing clinicians about individual patient care. The objectives of this study were: 1) to explore the feasibility of extracting and displaying population-based information from an actual clinical population's database records, 2) to explore specific design features for improving population display, 3) to explore perceptions of population information displays, and 4) to explore the impact of population [...]

Electronic health records (EHRs) have potential to facilitate reliable communication and follow-up of test results. However, limitations in EHR functionality remain, leading practitioners to use workarounds while managing test results. Workarounds can lead to patient safety concerns and signify indications as to how to build better EHR systems that meet provider needs.

A critical consideration when applying the results of a clinical trial to a particular patient is the degree of similarity of the patient to the trial population. However, similarity assessment rarely is practical in the clinical setting. Here, we explore means to support similarity assessment by clinicians.

Eliciting knowledge from geographically dispersed experts given their time and scheduling constraints, while maintaining anonymity among them, presents multiple challenges.