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Electronic health records (EHRs) contain valuable patient information, yet certain aspects of care remain infrequently documented and difficult to extract. Identifying these rarely documented elements requires advanced informatics approaches to uncover clinical documentation patterns that would otherwise remain inaccessible for research and quality improvement.This study developed and validated an informatics approach using natural language processing (NLP) to detect and characterize rarely documented elements in EHRs, using spiritual care documentation as [...]

In 2023, AMIA's Inclusive Language and Context Style Guidelines (the "Guidelines") were approved by the Board of Directors and made a publicly available resource. This work began in 2021 through AMIA's DEI Task Force and subsequent DEI Committee; many members provided input, feedback, and time to create the Guidelines. In this paper, the authors provide a transparent account of the origin, development, contents, and dissemination of the Guidelines and share [...]

The current study examined the moderating effect of self-control on the relationship between attitudes toward cybersecurity and risky online behaviors among direct care nurses.A cross-sectional study collected data from 260 direct care nurses in Saudi Arabia using a self-reported questionnaire. Hierarchical multiple regression analysis and simple slope analysis examined the moderation effect of self-control on the relationship between attitudes toward cybersecurity and risky online behaviors.We found that a better attitude [...]

Terminologies, such as Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) and Solor, assist with knowledge representation and management, data integration, and triggering clinical decision support (CDS) rules. Semantic relations in these terminologies provide explicit meaning in compositional expressions, which assist with many of the above-listed activities.The aims of this research are to: (1) identify semantic relations that are not fully present in SNOMED CT and Solor and (2) use [...]

While nursing summaries in electronic health records are used for initial orientation to a patient's status, research on nurses' use of these summaries remains scarce. This case study conducted an eye-tracking simulation to identify (1) key information types (orders, vital signs, etc.), (2) frequently paired information types, and (3) common sequential patterns of information types within nursing summaries as nurses review simulated patient cases.We recruited 33 medical-surgical nurses from a [...]

Hypertension is a significant contributor to cardiovascular disease, yet evidence-based blood pressure (BP) control practices are inconsistently applied. The Collaboration Oriented Approach to Controlling High Blood Pressure (COACH) is a digital clinical decision support tool designed to improve BP self-management and support clinician workflows. While the patient perspective on COACH has been evaluated in a separate study, this study evaluates organizational readiness for COACH implementation across three health systems using [...]

This study aimed to describe human-centered design of clinical decision support (CDS) for children with metabolic diseases at high risk of rapid decompensation, assess the influence of CDS on care processes and patient outcomes, and share insights from the implementation.A CDS was designed in collaboration with pediatric genetics experts to provide accelerated triage and recommend dextrose-containing fluids for patients metabolic conditions. Formative usability testing was conducted with emergency department (ED) [...]

Clinical decision support (CDS) tools in electronic health records (EHRs) often face low uptake due to limited usability, workflow integration, and other implementation issues. We recently designed and implemented the STRATIFY-CDS tool, which calculates a validated risk-prediction model and recommends disposition for emergency department (ED) patients with acute heart failure. Despite applying human-centered design and implementation science strategies, initial utilization in the first 3 months of the STRATIFY-CDS tool was [...]

Hospitals are looking to AI and other innovative applications to help alleviate provider burden and dissatisfaction associated with clinical documentation in oncology. Ambient artificial intelligence (AI) scribes are a promising technology to address these issues. However, they generally have not been optimized for oncology. This study aimed to evaluate an ambient AI scribe application with oncology providers to determine opportunities and potential challenges.This prospective pilot study of a scribe application [...]